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THE LIBRARY

THE UNIVERSITY

OF CALIFORNIA

LOS ANGELES

GIFT OF

SAN FRANCISCO
COUNTY MEDICAL SOCIETY

THE NEW SYDENHAM

SOCIETY.

INSTITUTED MDCCCLYIII.

VOLUME XXX.

DISEASES OF THE SKIN,

IXCLUDIXG THE

EXANTHEMATA.

FERDINFAND HEBRA, M.D.,

PROFKSSOR FUB DEBMATOLOGTE AN DF.H UNIVKHSITAT. IIIIMARARZT DKR ABTlIErLUNO yUR
IIAITKRANKIIEITKN IJI K. K. ALIO. KRAXKENII AUSE IN WIEN, ETC. ETC.

VOL. I.

TEANSLATED AXD EDITED BY

C. HILTON FAGGE, M. D.,

MEMBER OP THE ROYAL Cri.LEGE OF PHYSICIANS;

ASSISTANT-I'IIYSICIAN TO, AND LECTURER ON EXPEIIIMENTAL PIIILOSOPIIY AT

OlY'S HOSPITAL; PHYSICIAN TO THE ROYAL INFIRMARY FOR THE

DISEASES OF CHILDREN AND WOMEN.

THE NEW SYDENHAM SOCIETY,
LONDON.

MDCCCLXVI.

561

PRINTED BY J. E. ADLARD,

BAETirOI.OMT-W CI.OSl!.

UitTSTf

JlfO

AUTHOE'S PREEACE

ENGLISH EDITION.

It was with great pleasure that I acceded to the request of the
Council of the New Sydenham Society, communicated to me by
their courteous Secretary, Mr. Hutchinson, that I would allow my
work on 'Diseases of the Skm' (which forms part of Yirchow^s
' Handbuch der speciellen Pathologie und Therapie ') to be trans-
lated into the Enghsh language. Of the compUmeut paid to me by
the Society in making this request I am the more sensible, because
Enghsh literature is already by no means poor in treatises upon
cutaneous affections. Thus, although, during the last century, this
branch of medical science was cultivated with zeal both in Germany
and J^^rance, it was England, the country of Willan and Bateman,
wTiicETtook the largest share in what may be termed the Beformation
of Dermatology. ^

In fact, not only all later English writers on diseases of the
skin, but also those of every other country, have made use of the
Classification of "Willan in arranging the subdivisions of their own
systems, or, indeed, have even adopted this Classification without
modification.

Within the last few years, in particular, several English physi-
cians have pursued the study of cutaneous affections, and have suc-
ceeded in adding very considerably to the general fund of knowledge
in this department of medicine. Among these I must mention
especially my talented friend Mr. Erasmus Wilson, as well as
Dr. Anthony Todd Thomson and Dr. T. McCall Anderson. The
A\ urks of these writers, whether systematic treatises, or monographs
;^ upon general dermatology, or upon particular diseases of the skin,
have rendered them famous throughout the Continent as well as in

VI PREFACE.

their own country. I might name many others who have won for
themselves a deserved reputation, either by excellent articles in the
medical journals (Hutchinson, Addison, Gull), or by the success
with which they have devoted themselves to the treatment of cuta-
neous affections (Startin, HiUier, Tilbury Fox).

I have therefore felt pecuHar satisfaction in finding my work on
'Diseases of the Skin'' admitted to a place by the side of those
English treatises of which I cherish so liigh an opinion. With
reference to Dr. Hilton Fagge's translation, I will only say that I
have found reason to express the fullest confidence in his knowledge
of the subject, as well as in the zeal with which he has executed the
task set before him.

I have also to mention, that there is, in some respects, a greater
unity in the translation than in the original German edition.
Certain parts which had been written by my colleagues have been
entirely rewritten by myself.

Moreover, there are in the original several errors by which the
meaning is perverted ; all these have been corrected in the present
volume. Consequently, many little changes will be found, which
are to be regarded as improvements. In fact, in all these points,
the English translation is more correct than the German edition of
my work.

Hebea.

Vienna, November, 1866.

TEANSLATOE'S PEEEACE.

In submitting to the Members of the New Sydenham Society a
first volume of the translation of the important work of Professor
Hebra on ' Diseases of the Skin/ I think it necessary to add a few
words to the preface written by the distinguished author.

There will always be a difference of opinion as to the best
course to be adopted in translating from one language into
another : whether the expressions used in the original should be
transplanted^ so to speak, into the fresh soil, in the hope that they
may still flourish, or whether the object should be to convey the
opinions of the author, in the words commonly employed by those
who write in the language of the translation. It has been my aim
to follow an intermediate course. But, although I believe my trans-
lation to be more literal than some which have been placed in the
hands of the English Medical Public, I think, in looking over the
pages which foUow, that I am more likely to be blamed for depart-
ing from the exact mode of expression in the German text than for
adhering to it too closely.

There are, however, reasons which lead me to believe that a justi-
fication may be found for this. Every sheet of the translation has
been read over by Professor Hebra, and every passage in which I
felt any doubt as to the faithfulness of the translation, or as to the
sense of the original, was underlined by me, and has been accepted
by him, or corrected so as to convey the right meaning. It is the
more necessary to make this remark as there are, at least, one or
two instances in which statements arc made in the original text, dia-
metrically opposite to what was intended by the author. In these

Vlll PREFACE.

cases, the English edition, of course, differs ahogether from the
German.

Again, I am convinced that a very literal translation is often
really less accurate than a more free one. Words and forms of
expression which are commonly used in a language are often intro-
duced loosely and without definite meaning ; whereas, when trans-
ferred to another language, they convey to the reader ideas of a
precise kind which were not at all intended by the original author.

Professor Hebra has mentioned that certain chapters have been
rewritten for the English edition of this work. These are Chapters V
and VI, " On the Affections of the Glandular Organs of the Skin,^'
and the greater part of Chapter XV, of which Herpes is the subject.
Moreover, in the chapters on Morbilli and Scarlatina, certain details
as to the internal diseases which occur as complications or sequelae
of these exanthemata have been omitted. These omissions brins;
the volume back to a size probably nearly equivalent to that of the
original, for the chapters rewritten by Professor Hebra occupy a
much larger space than those wliich they have replaced.

It may also be well to remark that the arrangement of the work
itself differs from that adopted in the German edition. In the latter,
a tabular construction is followed throughout ; there are no separate
chapters j and headings in small type not rarely correspond to others
at intervals of more than a hundred pages. Such a plan would, I
think,"give an English reader great inconvenience ; and, therefore,
the present volume has been thrown into chapters ; of which one
(Chapter VII) is made up of the isolated paragraphs above referred
to, all of which are thus collected together. The tabular arrangement
of the original is, however, preserved in the Table of Contents.

]\Ieution is made incidentally of a fact which wiU, I think, be
deemed of interest in reference to the writings of "VTillan. Pro-
fessor Hebra quotes (vide note, p. 15) from a German translation
of a work of Willan^s, pubhshed at Breslau in 1799. Now, the
earliest treatise on diseases of the skin by the great English derma-
tologist, contained in any of the large medical libraries in London,
is the quarto dated 1808 ; and the only reference I have been able

PREFACE. IX

to find to any previous work of his on this subject is the state-
ment that the Pothergühan gold medal had been awarded to him
in the year 1790, by the Medical Society of London, for a Clas-
sification of Cutaneous Affections. It would, therefore, seem that
a publication which was at the time deemed worthy of translation
into German has fallen into complete oblivion, having no doubt been
eclipsed by the well-known later writings of its author.

In conclusion, I have only to express my great obligations to my
friends. Dr. Welch, Dr. Mackenzie Bacon, and Dr. A. B. Shepherd,
for having very kindly assisted me in correcting many of the proof-
sheets of the present volume.

C. H. P.

Trinity Squake,

southwakk ;

Nov., 1866.

CONTENTS

FIRST VOLUME.

CHAPTER I.

On the General Pathology and Symptomatology of

FTANEOus Diseases

•

I. Pfimary symptoms or forms of Efflorescence

1. The maciüe or spot

2. The papiile

3. The tubercle .

4. Tlie wheal

5, The tumour

6. The vesicle

7. The bleb

8. The pustule .

II. Seconda/ry symptoms

1. The excoiiation

2, The cutaneoiis ulcer

3. The fissure

4. The scale

CONTENTS.

5. The crust ....

6. The lamellated crust .

7. The scar ....
III. On the Distribution of En(^tions over the SJcin

PAGE

20
20
21

CHAPTER II.

On the Diagnosis, Etiology, Treatment, and Classipica
TioN OF Cutaneous Disease in general
I. Diagnosis ....
II. Etiology ....

III. Ti'eatment ....

IV. Classification

26
33
38
43

CHAPTER III.

Class I. — Hyper^müe Cutanea

A. Active Hyper8einia3 . . . .

A. Idiopathic active Hyperaemiaa .
Erythema congestivum idiopathicura .

1. Erythema traumaticum

2. Erythema caloi-icum

3. Erythema ab acribus, seu venenatum

B. Symptomatic active Hypersemia^

1. Erythema infantile, seu Roseola infantilis

2. Erythema variolosum. Roseola variolosa

3. Roseola Vaccina ...

B. Passive Hyperaemise

A. Idiopathic passive Hypersemise

1. Livedo mechanica . . .

2. Livedo calorica

B. Symptomatic passive Hypersemiffi

50
50
51
51

52
53
53

55
56
58

60
60
61
62
63

CONTENTS.

XIU

CHAPTER IV.

Class II. — An^mi^ Cutanea ....
A. Anaemia of fhe Skin, from absolute want of liloocl

A. Anaemia from haemon-liage

B. Anaemia consequent upon disease

S. Anaemia of the Skin, catised by perverted innervation

PAGE

67
68
68

CHAPTER V.

Class III. — Anomalie Secretionis Glandulartjm Cu-

TANEARUM . . . . , .71

Functional disorders of tbe Cutaneous Glands . . 74

A. Morbid states of the Materia Perspiratoria . . 74

(a) Bromidi'osis universalis . . .75

(&) Bromidrosis localis . . . .76

B. Functional disorders of tlie Sudoripai'ous Glands . . 78

1. Quantitative changes in tbeir secretion . .78

A. Hyperidrosis . . . . . .78

a Hyperidrosis universalis . . .78

ß. Hyperidrosis localis . . . .83

B. Anidrosis . . . . . .91

2. Qualitative changes in their secretion . . .92

Chromidrosis . . . . . .93

Haematidrosis . . . . . .93

Galactidrosis . . . . . . 96

Uridrosis . . . . . .97

XIV CONTENTS.

CHAPTER VI.

C. Affections caused by morbid states of the secretion, or

by changes in the structure of the sebaceous glands . 99
I. Affections caused by the secretion of sebum in excessive

qiiantity . . . . . . .99

(i) Without impediment to its excretion . . 100

Seborrhcea ...... 100

1. SeboiThcea oleosa, seu adiposa . . . 105
(a) On parts of the body not covered with hair . 105
(fe) On parts of the body covered with hair . 107

2. Seborrhcea sicca, seu squamosa . . . 108
(a) On parts of the body not covered with hair . 109
(h) On parts of the body covered with hair . 109

General characters of seboiThcBa . . . 110

Distribution ..... 110

Seborrhcea congestiva, s. Impus erythematosus . 114
Etiology . . . . . .116

Ti-eatment . . . '. . .118

(2) With impediment to its excretion . . . 121

Comedones ..... 122

Milium, s. Gridum .... 126

Vitiligoidea ..... 127

Sebaceous warts and tumours . . . 130

Molluscum contagiosum .... 131

n. Affections in which the sebaceous secretion is diminished

in quantity ...... 137

CHAPTER VII.

Class IV. — Exudationbs Cutanea
General remarks . . . . . ,

A. Acute exudative dermatoses

A. Acute, contagious, exudative dermatoses , .

B. Acute, non-contagious, exudative dennatoses

B. Chronic exudative dermatoses . • ,- ■

140
140
141
142
145
152

CONTENTS.

CHAPTER VIII.
A. Acute, Contagious, Exudative Dermatoses.

Morbilli ......

Symptoms ......

Irregulai' forms .....

1. Varieties in the localisation of the rasli

2. Varieties in the duration of the stadium floritionis

3. Prolongation of the period of desquamation .

4. Morbilli apyretici ....

5. Febris morbillosa sine exanthemate

0. Varieties in the appearance of the rash

7. Combinations with other

8. Complications
Diagnosis

Pathological anatomy",
Sequelaa
Prognosis
Etiology
Treatment

skin-affections

PAGE

156
157
162
162
163
164
164
164
165
166
167
176
177
177
180
181
185

CHAPTER IX.

Scarlatina ....
Symptoms ....
Modifications ....

1. Prolongation of the period of latency

2. Irregular development of the rash

3. Irregularities in its duration or intensity

4. Irregularities in the process of desquamation

5. The " scarlatina sine exanthemate"

6. Irregulai'ities in the form of the rash .

7. Combinations with other cutaneous affections

8. Complications ....

188
189
193
193
193
194
195
195
195
197
198

XVI

CONTENTS.

Sequelae

Prognosis

Etiology

Diagnosis

Treatment

CHAPTER X

Variola
Symptoms

Anomalies in its course
IiTegular forms of the rash .
Complications .

A. Other diseases of the skin

B. Diseases of mucous membranes
c. Diseases of the eye

D, Diseases of internal organs
Sequelae
Diagnosis
Prognosis
Treatment

CHAPTER XI.

Vaccinia, or Cow-pox ....
Irregular forms ....

I. Local modifications

(a) Variola Vaccina atrophica

(b) Roseola Vaccina

(d) Variola Vaccina bullosa, Pemphigoides

(e) Variola Vaccina fiirunculosa

if) Erysipelas Vaccinae . . _

{g) Variola Vaccina ulcerosa .

(h) Gangi'cne . . . .-

CONTENTS.

XVll

II. Modifications affecting the System generally
(a) YacciniolEe ....
(6) Vaccinal fever

(d) Diseases of the glandular organs .

PAGE

283
283
283
284
284

CHAPTER XII.
B. Acute, Non-contagious, Exudative Dermatoses.

The Polymorphous Erythemata .

. 285

I. Erytliema exudativum

. 285

A. Eiytliema exudativum multiform.e

. 285

B. Erytliema nodosum

. 289

Pellagra .....

. 293

Acrodynia .....

, 297

II. Roseola .....

. 299

III. Urticaria .....

. 301

Diagnosis .....

. 306

Morbid anatomy ....

. 307

Etiology .....

. 307

Treatment .....

. 310

CHAPTER XIII.

The Dermatitides proper

. 312

A. Dermatitis idiopathiea

. 312

1. Dermatitis traumatica .

. 312

2. Dermatitis venenata .

. 313

3. Dei-matitis calorica

. 313

(a) Dermatitis ambustionis

. 314

1st degree — Erythematosa .

. 314

2nd degree — BuUosa

. 315

3rd degree — Eschavotica

. 316

XVIU

CONTENTS.

PAGE

Prognosis ..... 318

Ti-eatment . . . . .318

(6) Dermatitis congelationis . . . 322

1st degree — Erythematosa (Pernio) . 324

2nd degi-ee— Bullosa . . .325

3rd degree — Esctai'otica . . . 325

Ti-eatment . . . . .326

CHAPTER XIV.

B. Dermatitis symptomatica

I. Dermatitis ei-ythematosa
. Erysipelas
Symptoms .
Varieties .
In form .
In extent
In seat .
Diagnosis .
Pathological anatomy
Etiology .
Prognosis .
Treatment .
II. Dermatitis phlegmonosa
Furunculus .
Anthrax
Glanders

Necrogenic pustule
Pustula maligna
Treatment .

330

331

333

334

335

337

338

339

342

346

347

348

351

352

354

355

CONTENTS.

XIX

CHAPTER XV.

PAGE

The PHLYCT.ä;NOSES . . . . . . 359

I. Herpes ....

. 359

History

. 359

Definition

. 365

Species

. 366

1. Hei-pes facialis, sen labialis

. 368

2. Herpes progenitalis, seu prseputialis

. 370

3. Herpes zoster .

. 372

(a) capülitii

. 375

(b) faciei

. 375

(e) nuchae .

. 376

{d) brachialis

. 376

(e) pectoralis

. 376

(/) abdominalis

. 376

((/) femoralis

. 377

4. Herpes Iris et cü-cinatus

. 378

Etiology-

. 381

Treatment

. 382

II. Miliana

. 383

Etiology

. 390

Diagnosis .

. 391

Prognosis .

. 392

Treatment .

. 393

III. Pemphigiis acutus, sen Febrilis

. 394

DISEASES OF THE SKIN.

CHAPTER I.

ON THE GENERAL PATHOLOGY AND SYMPTOMATOLOGY
OF CUTANEOUS DISEASES.

The integument^ as an integral part of the organism^ is liable to
no other morbid processes than those to which the other organs of
the human body are subject. Thus, there are diseases of the skin,
Avliich are caused by hypersemia, anEemia, exudation, and hsemorrhage;
and we also meet with neuroses of the skin, and find it presenting
new growths, or affected by hypertrophy or atrophy. The anato-
mical conditions and the superficial position of tlic skin, as well as
the extent of its surface do indeed in some degree modify its diseases.
But of the peculiar forms thus produced, some, such as the ulcerative
processes, and the parasitic growths, occur also in analogous tissues,
such as the mucous membranes. And the remaining difl'erences
concern chiefly the etiology and symptomatology of cutaneous aff"ec-
tions, and do not consist in any essential peculiarity in the nature of
the disease.

What however is altogether special to afl'ections of the skin, is
their symptomatology , that is to say, the nature of the appearances
by which the various pathological processes manifest themselves to
our senses.

On a general survey of these appearances, it is impossible to
overlook the fact that the dermatonoses present a certain uniformity
in their configuration, and that they have also a definite mode of
development, and of retrogression. And this leads directly to the
conclusion, that the determining agent in the production of the
symptoms of cutaneous disease, is not so much the general pathological

2 GENERAL SYMPTOMATOLOGY.

process, as the local disturbance to which it gives rise. In other
words, the cause of the peculiar appearances met with in the
dermatonoses, lies in the change which these diseases produce in
the organs which make up the skin. For example, pustules, which
do not essentially differ in form, are caused by the variolous process
and by scabies, as well as by tartar emetic ointment, and by mere
mechanical friction. Yesicles appear in the train of certain general
diseases, which resemble perfectly those produced by the inunction
of croton oil. Again, precisely similar deposits of pigment are pro-
duced by external irritants, and by affections of the internal organs.
And thus, from any individual appearance, we can seldom infer the
cause of the disease. We have always to pass in review the whole
of the symptoms, which belong to each cutaneous affection.

And yet it is indispensable to have an accurate acquaintance with
each of the appearances caused in the skin by the various morbid
processes to which it is liable ; and it is necessary not only to know
their oric/inal form, but also to be familiar with the further changes
which they undergo, with their mode of ^involution, and with their
pathological anatomy.

Under the term Efflorescentice aitanea (Hautblüthen, Efflo-
rescenzen, eruptions), it is usual to group together many of the
symptoms of cutaneous disease, which differ altogether from other
pathological appearances, in their determinate form, their position,
and their course, as well as in the regularity of their development and
retrogression. And it is the practice to give certain special names
to the various forms of efEorescence, which are distinguished by
characters of their own.

Now we have no intention of disturbing the established termi-
nology and definitions of these different forms of efflorescence. On
the contrary, we hold that designations once adopted should always
remain fixed, and should be closely adhered to. But we shall also
carefully avoid aU unnecessary and too refined distinctions, specifying
those differences only, which are of an essential kind.

Some of the appearances observed in cutaneous diseases are caused

* The term involution is employed in this and other works to indicate that
stage of a disease, which succeeds the full development of the pathological
change, and during which the restoration of the normal condition of the part is
going on. Thus, in variola, it is applied to that period which follows the com-
plete formation of the pustules, and in which these become couverted into
crusts. — [Ed.]

PRIMARY rORMS OF EFFLORESCENCE. 8

directly by the deposition of morbid products in the skm. These
bear the name of Primary symptoms or eruptions^ Efflorescentia
cutanea p-imarm. But these eruptions often afterwards undergo
further development, and are subject to changes of a \italj chemical,
or mechanical kind. To the appearances thus produced we apply
the name of Secondary symi^toms.

Under the first head, we include (i.) the spot or macule — Macula
(Fleck). (2.) The papule— Pö/j?«/ü! (Knötchen). (3.) The tubercle—
Nodus seu Tuberculum (Knoten). (4.) The tumour — Phyma
(Knollen). (5.) The wheal — Tomphus seu Urtica (Quaddel).
(6.) The vesicle — Vesicida (Bläschen). (7.) The bleb — Bulla
(Blase) ; and (8.) the pustule — Pustula (Eiterblase).

AmoDg the secondary appearances we enumerate — (i.) The
excoriation — E.vcoriatlo (Hautabschürfung). (2.) The ulcer —
ulcus (Geschwür). (3.) The fissure — Ehagades (Schrunde).
(4.) The scale — Squama (Schuppe). (5.) The crust — Crusta
(Kruste). (6.) The lamellated crust — Crusta Lamellosa (Schuppen-
grind); and (7.) the cicatrix — Cicatrix (Narbe).

I. — Primary symptoms or forms of Efflorescence.

(i.) The macule or spot {JIacula, Fleck, Kelis, Tache) includes
every change in the normal colour of the skin, arising from disease,
and not uniformly distributed over the whole surface of the body.
When the skin is universally aflected, we employ the term dis-
coloration, Becoloratio, Dyschromasia — (Missfätbung) .

The colour of maculae is either one of the various shades of red^
or white, grey, yellow, green, blue, brown or black. They may either
be punctiform, or may vary in size from that of a lentil to that
of a bean, of a finger-nail, of a fourpenny or sixpenny-piece, a half-
crown, the palm |of the hand, &c. In form, they may be divided
into round, oval, elongated, circinate, and serpentine.

Their seat is sometimes in the vessels which supply the papillae of
the cutis, sometimes in the pigmentary layer of the cuticle.

Various morbid processes may be concerned in the formation of
maculae. They may arise either from simple hyperaemia, or from
exudation into the tissue of the cutis, without elevation of its
surface, or from hsemorrhage and its results, or, lastly, from anoma-
lies of pigmentation.

4 GENERAL SYMPTOMATOLOGY.

All these cliaiiges iu the normal colour of the skin bear the
general name of maculee; but we have for some forms of them
special denominations. Thus the term Roseola (Ptöschen) is applied
to red spots^ of a rounds oval^ or elongated form, in size between
that of a lentil and that of a finger-nail, when the redness disappears
beneath the pressure of the finger. On the other hand, when the
redness does not so disappear, the name Fnrpura is used; and this
is again subdivided according as the maculse are large or small, or
simply punctiform — Peteehm, or in the form of strise — Vibices, or
occupying large tracts of skin — Ecchymosls. Again, rashes which
cover, uninterruptedly, portions of the integument as large as the
palm of the hand, or larger, and which disappear beneath the pres-
sure of the finger, are called '^Eryihemata (Erytheme).

Those blushes which surround the periphery of other eruptions
receive the name Areola or Halo (Hof.).

Flat Teleangiectases, the so-called Nsevi vasculares, also form red
spots ; but these are readily distinguished from Roseola, Erythema y
or Purpura, by the presence of the distended varicose vessels which
cause the disease, and which are generally visible with the naked
eye. Moreover, in these affections it requires the application of a
more severe and continued pressure, to make the redness even for a
short time disappear.

White spots, produced by deficiency of pigment, and varying in
size from that of a lentil to that of the palm of the hand, or even
occupying the whole surface, are called Achroma, Vitiligo (alba levior)
if acquired; Leucopathia, Albinismits, if congenital. Darker patches
caused by increased deposit of pigment may be observed at the
circumference of these white patches. The openings of the hair-
sacs are also seen on them unaltered ; and the growth of the hairs

1 Although we fiud these terms applied throughout dermatologlcal works in
pretty strict conformity with their definitions, yet it must be admitted that
some names are met with, which do not answer to the rules we have laid down.
A7e have examples of this in the Roseola rheumatica (a red rash, which takes
the form of maculae, but which does not disappear on pressure, and, as is well
known, is caused by haemorrhage), and in the Erythema papulutum, tuberculatum,
atimdare, iris, gyratum, nodostim, &c., (forms of efflorescence, having a red colour
and a raised surface, varying in size between that of a pea and that of a hen's
e^g, of an annular shape, or resembling papules, tubercles, &c.). However,
the introduction of a scientific terminology in the study of cutaneous disease,
will probably be tiie work of the immediate future. I shall at least attempt
to prepare the path towards its accomplishment.

PRIMARY FORMS OF EFFLORKSCENCE. 5

whicli are themselves mostly white^ remains iinafFected. These
characters enable these affections to be readily distinguished from
flat cicatrices.

Brown or black spots, produced by excessive deposit of pigment,
have various names, (i.) Chloasmata (Pigment, ]\lother, or Livers-
spots). These cover spaces as large as a half-crown-piece, or as the
palm of the hand, or are even larger still. They are met with on the
face, particularly on the forehead, and also on the trunk, and on the
extremities, and they do not desquamate. (2.) Lentigines or Hj^lie-
tides — -Sun spots (Linsenflecke, Sommersprossen). These are yellow
or brown spots, of the size of a lentil, which are found in large numbers
on the face and limbs. (3.) Pigment marks — ^Ncevus Spiliis (Pig-
mentmaale). These are brown or black spots, generally round,
scarcely or not at all elevated, and of the size of a lentil or of a
fourpenny -piece. They are generally solitary, and occur chiefly on
the face, back, and extremities.

Yellow, blue, and green discolorations of the surface are observed
during the involution of hsemorrhagic spots ; they are always con-
fined to the seat of the original heemorrhage, and may be easily
recognised by the fact, that the colour is not the same over the
whole of the spot. On the contrary, they have a marbled appear-
ance, and generally display at the same time all the three colours
which we have named.

Spots, which are simply blue, and present no other colour as well,
are, if they disappear on pressure, the result of passive congestion,
or blood-stasis, and occur chiefly at the distal parts of the body,

' The name Liver-spots (Leberflecke) led to, or arose from, the erroneous
opinion that they were caused by hepatic diseases. For tliis idea there is no
foundation whatever. Disease of tiie liver, such as atrophy, may cause deposits
of bile-pigment in the skin ; but this produces a yellow or brown discoloration
of the whole surface of the body.

^ Here, also, we meet with a mistake which is very widely diffused, the
notion that these pigment-spots are due to the influence of the sun's rays.
Careful observation, however, teaches us that this is not the case. The proof
of this statement we shall furnish hereafter.

3 If the term Nsevus — mother's mark, answers to a congenital modification
of the colour of certain parts of the skin, it is not strictly applicable to the
appearance whicli we are now describing ; for these spots are very rarely seen
in infants, and almost always show themselves first during adult life. In our
Lying-in hospital, in which there are more than 7000 births every year, there is
abundant opportunity to convince one's self of this fact.

6 GENERAL SYMPTOMATOLOGY.

such as the face, the hands or the feet, in cases of defective circu-
lation.

A black colour affecting parts of the skin — Nigrities partialis,
Panmis melanem — is met with on the face, on the areolae of the
breasts, and over the linea alba of pregnaiit women, and also in the
scrotum of men, where it is a local change.

Discolorations — Decolorationes, Bysclifomasia (Missfärbungen),
that is to say, more or less uniform alterations in the colour of the
whole surface, present various appearances. There is the pale,
waxy, death-like hue (Todtenfarbe) which is seen in chlorosis, in
anfcmia, and in the different cachexise. There is the yellow, green,
brown, grey, or even black colour, which is due to the deposit of
pigment in the skin — of biliary colouring matter in jaundice, of
nitrate of silver in argyria, of an excess of the normal cutaneous
pigment in melasma. And lastly, there is the more or less deep
blue or bluish-black tint, which is produced by disturbance of
the circulation, as in the so-called cyanosis or morbus cseruleus.

!Maculfe vary in the course which they run, and in the duration
of their existence. The spots of roseola or of erythema always
quickly disappear, and either leave no trace of their presence, or are
followed by desquamation and deposit of pigment in the parts which
were before reddened. On the other hand, spots caused by
teleangiectasis are almost always permanent, and at most vary only
in the depth of their red colour, and in its tint. So again the
white, brown, and black maculae, which arise from deficiency or
excess of pigment, very seldom undergo changes of hue, though
they may spread over a larger surface. The yellow, blue, and green
discolorations, which are the result of haemorrhage, have generally a
duration of from one to three weeks, according to the quantity of
extravasated blood. During this time they present several changes
of colour, so that, from being at first bluish-red they become blue
or bluish-black, then greenish-yellow, and finally quite yellow.
The blue, or cyanotic colorations, correspond in duration to the
causes which produce them \ and when these are removed, vanish
completely without leaving behind them any indication of their
presence. This is true also of the other forms of general discolora-
tion of the skin.

(2.) The papule or pimple {Tabula, Knötchen, Blätterchen) .
These names are applied to any morbid change in the skin, which
forms a solid projection above the surface^ in size between a millet-

PRniARY FORMS OF EFFLORESCENCE. 7

seed aud a lentil,, and containing within it no fluids so far as can be
seen with the naked eye.

Their colour may be that of the healthy skin, or may be of any
shade of red. Papules may also be white^ brown, or black, or of a
livid hue.

Their magnitude varies from that of a millet-seed — Milium,
Pajonla miliares, miliform.es, to that of a lentil — Lenticnla — Papul(B
lenticulares. j\Ioreover, pins-heads and hemp-seeds may also be made
use of as comparative terms to indicate more accurately their size.

In form they are distinguished as pointed, Paimlce acutcB — as flat,
T. plana. — conical, P.conicce — semi-globular, P. glohosa.

Papular eruptions are seated sometimes in the papillae of the
cutis ; sometimes in the deeper layers of the epidermis ; sometimes,
and indeed most frequently, in the follicular apparatus of the skin.
Thus, in one instance, they are due to the enlargement of already
existing papillae, or to the formation of new ones. In another case,
they are produced by exudation into the rete mucosum, or by
extravasation of blood into the same tissue. In other instances
again, it is a sebaceous gland, which, having undergone degeneration,
or having become distended by its secretion, causes an elevation
above the surface of the skin. Lastly, and this is the most common
case — the hair-sac, or rather the margin of the canal in which the
hair is lodged, is the special seat of the papule. It is easy to
convince one's self of this, either by obser\'ing cases of cutaneous
disease with the naked eye, or by examining papules with the
magnifying glass, and, after their removal, with the microscope.^

■^ My view with reference to the mode of origin of those papules (and vesicles)
which are seated at the entrance of a hair-sac, is as follows. As is well known,
the whole sac is filled with epidermis (the so-called root-sheath) so completely,
that there .is no free space between the hair and the wall of the follicle.
This part of the epidermis which is thus formed within the follicle and fills it,
is uninterruptedly continuous with the external cuticle, which arises from, and
covers the adjacent papillfe. Now when the vessels which supply the seba-
ceous glands or the papilla of the hair, pour a drop of exudation into the in-
terior of the follicle, this must of course infiltrate the epidermic cells which
occupy that position. It is not, however, retained by them, but is transmitted
in tlie direction determined by the mode of nutrition (in der durch den Stoff-
wechsel gegeben Richtung), that is to say, outwards to the cells immediately
contiguous. This process is repeated, till at last the drop of exuded matter, or
the secreted fluid, reaches the horny layer of the cuticle. This resists its pres-
sure, and prevents the further progress of the fluid, for its cells have less power
of imbibition. Hence it becomes pushed forwards above the level of the sur-

8 GENERAL SYMPTOMATOLOGY.

The pathological processes, by which papules arise, may be
reduced to the following —

(a) Abnormal growth and accumulation of e]:)idermis round the
entrances of the hair-sacs. The tubular sheaths of epidermis
(root-sheaths) which surround the hairs, and which normally
become imperceptibly detached, are under abnormal conditions
retained at the entrances of the sacs. This occurs first wdth the
innermost stratum, which is in immediate contact with the hair; the
next layer is then added ; and so on, till a cone of epidermis is
formed, consisting of concentric rings, and either perforated by a
hair in the centre, or having underneath it a more or less spirally
rolled-up hair, which cannot make its escape. This forms the Lichen
^yUar'is of Willan.

{Jj) Excessive secretion of hard and altered sebum, which fills and
distends the duct of the gland or of the hair-sac, and pushes before
it the lamina of epidermis, which covers the duct. Thus are pro-
duced the so-called white Comedones.

{c) Degeneration of the sebaceous gland, and conversion of it
into a white, globular, solid body, the size of a millet-seed. This
occurs in adults on the eyelids, and in the skin of the penis and
scrotum, and is termed Grutum or Milium. As observed in children,
it received from Willan the names Stro2)huhs albidus and S. cancUdus.

[d] Haemorrhage into the rete mucosum. The blood exudes in
the form of drops, which coagulate and push forward the horny
layers of the epidermis, and so produce papules. This affection is
the Lichen lividus of Willan.

(e) Exudations either upon the surface of the papillae, or into the
follicles in the way already described in the foot note to page 7.

(/) Hypertrophy of pre-existing sensory papillae, as, for example,
in ichthyosis.

{ff) GroAvth of new papillae, resembling those of the healthy skin ;
but larger, and generally pointed in form. These are met with in
condylomata, in frambccsia, &c.

rounding skin ; and thus a little projection is formed wliicli encircles the hair,
and is, in fact, a papide. If the process of exudation has now ceased, nothing
more occurs beyond the formation of the papule ; and this quickly disappears,
for the fluid exuded either evaporates or is absorbed, and the lamina of epidermis
•which formed its roof, separates as a furfuraceous scale. If, liowever, the
process goes a step further, and several drops of exudation are poured into the
follicle, the fluid gradually becomes visible beneath the epidermis, and thus
that form of eruption is produced, which goes by the name of the vesicle.

PRIMARY FORMS OP EFFLORESCENCE. 9

{h) Spasmodic contraction of the cutis (whether due to the action
of the organic muscular fibres which have been discovered in its
substance^ or to a contractihty inlierent in the connective tissue), by
which the looselj^-imbedded hair-sacs, with their ducts, are raised
above the level of tlie surface. It is in this w^ay that those papules
are produced, which are of the normal colour of the skin, and which
form the condition known as the Cutis anseriiia (Gänsehaut
goose-skin.)

Note. — According to the nomenclature introduced by Willan, all
cutaneous diseases caused by the formation of coloured papules, and
occurring in adults, are placed under the head Lichen. All papular
eruptions which appear in children bear the general name of StwpJm-
lus: — and papules which have the same colour as the rest of the
skin, are the distinguishing mark of a Prurigo. This nomenclature
may appear simple and judicious ; but the presence of papules, and
the peculiarities in their form and colour, cannot be applied as indi-
cations sufficient in themselves for the diagnosis of a disease. Tor the
determination of a cutaneous affection, its general appearance (das
Gesammtbild) is just as important as for the recognition of any
other internal or external malady. Moreover, as the symptoms
manifest themselves not at once, but in succession, and in a
definite order of development, it is necessary for the establishment
of the diagnosis of a disease that its whole course should be observed.
Although, therefore, we adopt the nomenclature of Willan for dis-
eases of the skin, yet we employ it only to denote i\\Q\vfo7-m. So
long for instance, as we regard a papular affection merely as a symptom,
we give it the name of Lichen ; but if we wish to indicate any par-
ticular papular eruption, it is necessary to associate with the name
of Lichen, an epithet defining it more narrowly.

The duration and the course of papules vary with the patholo-
gical processes to which they owe their origin. Thus those which
are caused by exudation into the follicles exist as papules for a very
short time only (from two to four days). Tor if the exudation conti-
nues, they pass into vesicles or pustules, or even into tubercles.
On the other hand, if they undergo involution, they gradually sub-
side, their fluid contents disappearing by absorption or evaporation ;
and a little discoid lamina of epidermis, which previously formed
their roof, remains as the only indication of their position. This
afterwards becomes detached as a scale. The skin beneath is then
left of a normal colour, or slightly darkened by pigment ; and the

10 GENERAL SYMPTOMATOLOGY.

entrance of the hair-sac, which is again pervious, is plainly visible.
Those papules which are caused by hgemorrhage have a longer
duration ; and those which are due to an accumulation of sebum, or
to degeneration of the sebaceous glands, remain longer still. Lastly,
papules which are produced by hypertrophy of the cutaneous
papillse, or by a new growth of similar structures, are altogether
permanent.

BemarJv. — A morbid appearance, which has received the name of the
Stigma or Umbo (Stippe, Punkt) is to be regarded as arising from the
union of the two forms of efflorescence which we have been describing.
It is a round, circumscribed red spot, not larger than a fourpeuny-
piece, which has in its centre a minute papule. Its origin may be
thus explained. The papule is caused by sweUing of the entrance of a
hair-sac, in the way already described ; and the surrounding halo
is produced by congestion of the vessels Avhich supply the corre-
sponding sebaceous glands. The stigma is always an ephemeral,
and never a permanent appearance : and it usually precedes the
formation of papules, vesicles, or pustules, as is the case, for instance,
in variola.

(3.) The tubercle {Tuberculum, Nodns, Knoten, Hübelchen) is any
solid swelhng of the skin caused by disease, which contains no
fluid, is as large as a lentil, bean, or hazel-nut, and is covered with
epidermis.

In colour tubercles correspond perfectly to papules ; for they
may be of the various shades of red, of the normal tint of the skin,
of a li^'id hue, or .white, brown, or black.

In, magnitude they are distinguished, as mentioned above, according
as they are of the size of lentils, of beans, or of hazel-nuts. Their
greater size constitutes the chief difference between them and
papules.

Their form is sometimes semi-globular, sometimes conical. They
may also be either pointed at the summit, or flattened, in which case
they may be said to be cylindrical.

The same structures of the skin, which are the seat of papules, are
also concerned in the formation of tubercles. The pathological pro-
cesses are also the same, with the exception of the spasmodic contrac-
tion of the skin (described under the heading h). The difference con-
sists simply in the fact that it is not one hair-sac only, but several
adjacent ones, which are affected simultaneously; or that not one
sebaceous gland only, but a whole group of them, undergoes degenera-

PRIMARY FORMS OP EFFLORESCENCE. 11

tion ; or that the quantity of exudation poured into a hair-sac^ or
into a sebaceous gland, or of blood effused into the same parts, or of
accumulated sebum, is so great that the appearance which is pro-
duced is larger, and is therefore termed tubercular. The same thing
apphes to the hypertrophies and to the new growths, only that here
still larger tracts of skin are attacked, and that, in consequence, the
resulting affection is also still more extensive.

The changes to which tubercles are liable are various. They may
undergo complete involution, their contents being absorbed, and their
covering of epidermis peeling off. They may become indurated by
organization, desiccation, or calcification of their substance; they
may soften and suppurate. Corresponding to these changes, the
duration of tubercles is also variable; but it is in any case much
longer than that of papules.

(4.) Wheals [PomjM, Urtica, Quaddeln) are solid forms of
eruption, which are but shghtly raised above the surface of the skin,
and of which the superficial area greatly exceeds the thickness.

Theh tint is generally red, pale red, or bluish-red. Wheals may
also be of a somewhat paler colour than the healthy skin ; and in
this case they are usually surrounded by a red ring.

The size of individual wheals seldom exceeds that of the thumb-
nail, and they are for the most part still smaller ; but by the fusion
of several which lie close together they may become bigger than the
palm of the hand.

With reference to their form, it may be observed that each wheal
generally resembles a segment of a sphere ; but they are sometimes
flat; and they may be circinate, or may present the appearance of
stripes, or have various serpentine forms.

The superficial layers of the cutis, and particularly the papillary
region, and the tissues immediately adjacent to the follicles, as well
as therete mucosum, are the seat of wheals.

Among the pathological processes by which they are produced
the most important are exudations either into the cellular layers^
surrounding the glands, or into the superficial strata of the cutis
generally. Moreover, haemorrhages, if very superficial and in large
quantity, may give rise to the formation of wheals, and some main-
tain also that they may be caused by spasms of the dermic structures.

^ "If the cougestiou is associated with increased exudation into the cellular
layers surrounding the glands, by which these are brought into a state of tur-
gescence, a wheal is the result." E-osenbaum, ' Zur Geschichte und Kritik der
Leiire von den Hautkrankheiten.' Halle : 1844, p. 78.

12 GENERAL SYMPTOMATOLOGY.

It is a peculiarity of these forms of efflorescence that they are not
liable to any further metamorphosis^ and that they therefore have
but a short duration, and disappear without being followed even
by desquamation.

(5.) The tumour (l^hjma, Knollen). This term is applied to
solid swellings, in size between a walnut and a man's fist, which are
covered with epidermis, and have their seat in the deeper layers of
the integument.

Their colour generally resembles that of the rest of the skin j but
they may also be red or brown. To indicate the size of a tumour,
it is compared to a walnut, to the egg of a pigeon, hen, or goose,
or to a child's or man's fist.

In form they are, for the most part, semi-globular or conical.
But tumours which are globular and pedunculated, or cylindrical
and flattened, are also occasionally seen. The cutis and the sub-
cutaneous connective-tissue, and the sebaceous glands, are the seat
of these aff'ections.

The pathological processes of which these tumours are the pro-
ducts are the following : — Accumulations of sebum in very distended
sebaceous glands {Tumores cystici); degeneration of these glands
{MoUvscum contagiosum), M'ith massive exudations and extravasa-
tions into the corium and the sub-cutaneous tissue ; and, lastly, new
growths formed within the substance of the integument. Upon the
nature of these processes depend both the duration of these tumours
and the further changes which they undergo.

(6.) Yesicles {Vesicula, Bläschen) are elevations of the horny
layer of the epidermis by transparent or milky fluid. In size they
correspond to pajndes.

Their colour depends on that of their contents, and of their base.
The former may be limpid or turbid, like whey, or mixed with
blood. The base, again, may be of a red or of a black colour. It
is, therefore, evident that the vesicles themselves may also present
these tints. The further examination of the fluid which they con-
tain shows that it has a neutral or alkahne reaction, and that it con-
sists of a blastema containing pus cells in small numbers.

An essential characteristic of the vesicle is its size; for only
those elevations of the epidermis, which are in size between a lentil
and a millet-seed, hemp-seed, or pin's-head, receive this appellation.
All those which are larger are reckoned as Bullse.

With reference to the form of vesicles the distinction is espe-

PRIMARY FORMS OF EFFLORESCENCE. 13

cially to be noticed, that on the summit of some of them is to be
found a small depression, concave towards the surface, and forming
a little saucer-shaped pit, which is called the umbilicus (Delle). ^

Most vesicles have more or less the form of a segment of a s])here
[Vesicnlce glohosa) : but mention is also made of some which are
conical {T'es'iadce conica).

Their seat is in the epidermis, between its mucous and horny
layers ; and they ai'e found both at the apertures of the hair-sacs,
and in the interfoUicular spaces. That the spiral ducts of the sweat
glands may also be the seat of vesicles (as is maintained by Eosen-
baum), can be demonstrated neither on the living subject nor on

^ As to the mode of origin of this appearance, authors are of different
opinions. Some, and among them Eichhorn and Rokitansky, think that the
umbilicus arises from the falling in of the centre of the vesicle, and its adliesion
to the cutis. Others maintain that the desiccation of the contents of the
vesicle beginning at its centre, causes it to shrink and to become depressed at
that poinL Both tliese views are contradicted by the simple observation, that
the formation of the umbilicus begins even during the development of the
papule, and that it only lasts till the moment when the whole of the fluid
within the vesicle has become yellow and purulent. Moreover, the umbilicus
exists only in those vesicles developed from papules, which occupy parts of the
surface in which hair-sacs are found ; and whether it belongs to a papule or a
vesicle, it may be seen to be perforated in the centre by one or more liairs,
particularly when it first makes its appearance.

My own opinion as to the mode of origin of the umbilicus, agrees perfectly
with that expressed by G. Simon ('Hautkrankheiten durch anatomische
Untersuchungen erläutert,' Berlin, 1851, pp. 97, 102, 131). I regard it, in
fact, as a direct consequence of the mode of formation of the vesicle, which I
explained when speaking of the papule.

The umbilicus is then for the most part caused by the circumstance, that the
exudation which generates a papule or vesicle, and which introduces itself between
the layers of the epidermis, cannot raise the cuticle so easily where this is con-
tinuous with the root-sheath of the hair, as at those points where this is not
the case.

Thus the formation of an umbilicus is the necessary consequence of the
change in the margin of the hair-sac, which results from the development of a
papule or a vesicle. The absence of an umbilicus, therefore, is a proof that the
eruption does not consist in a metamorphosis of the canals leading from the
hair-sacs, but has its seat in some other part of the integument.

An apparent umbilicus may indeed also arise by the circular arrangement of
an efflorescence round a central point, which is healthy, and presents no erup-
tion ; but such a central depression has a very different proportionate size (as
compared with the raised efflorescence) from that which we find in the case
of the true umbilicus. This last is never more than a small ])oint ; but the
false umbilicus may be as large as a millet-seed, or even as a lentil.

]4 GENERAL SYMPTOMATOLOGY.

the dead body ; neither by observation with the naked eye, nor by
microscopical investigation.

In regard to the pathological processes which are concerned in
the formation of vesicles, we find that these are almost exclusively
of an exudative kind. Hypersecretion of sebum may, however,
give rise to an eruption which has a vesicular form, but which
mostly contains a milky fluid.

The existence of vesicles in an unaltered state is never of long
duration. Either the membrane bursts and allows the contents to
escape, or the fluid disappears by absorption or desiccation, leaving
behind it the empty skin in the form of a scale; or, lastly, the
number of pus cells in the limpid fluid increases, its colour changes,
it becomes yellow, puriform, viscid ; and so the vesicle is converted
into a pustule.

(7.) Blebs {Bulla, Blasen) are distinguished from vesicles simply
by their magnitude. The line of separation is quite arbitrary, and
is generally drawn by comparing the bulla to the tubercle in size.
Thus, the definition of it will be that it is an elevation of the
epidermis, in size between a lentil and a gooseys egg, containing in
its interior a transparent, or a yellow and purulent fluid.

As to their colour, what has been said of vesicles applies also
to bullse, with this difference, that more importance is attached to
the colour and nature of the contained fluid in defining the vesicle
than in the case of the bleb. Thus, a large bulla may be filled
with yellow purulent fluids without being termed a ])ustule, which
would be the name given to a vesicle under similar circumstances.

Again, bloody serum is more frequently found in bulJse than in
vesicles. But blood by itself, without admixture with serosity or
pus, forms not bullse, but dark-red or black tumours (Knollen) ;
for it never remains fluid when extravasated beneath such a covering
of epidermis, but always coagulates.

The contents of bullfe have the same microscopical characters as
those of vesicles, so long as the fluid is transparent. The chemical
reaction also is always feebly alkaline or neutral, and never acid. A
considerable quantity of albumen is present, especially in the larger
bullee ; and sometimes the fluid also contains urea and uric acid.

On the other hand, the size and form of bullae are subject to
much more considerable variations than are those of vesicles. Thus
we meet with blebs of the size of lentils, beans, hazelnuts, or walnuts ;
or they may be as large as the eggs of pigeons, hens, or geese, or may

PRIMARY FORMS OF EFFLORESCENCE. 15

even attain the size of the fist or the palm of the hand. "We find
them semiglobular, or almost globular, and also conical ; distended
or flaccid (matsch) ; with a circular or oval circumference and base ;
and lastly, polygonal, indented, tailed, chciuate or half-circinate.
Moreover, in describing bailee, it must not be overlooked that some
of them are surrounded by a red border {Areola, Hof.), which in
other instances is wanting.

In reference to their position and mode of development, it is to
be remarked that they are seated in the epidermis, between its horny
and mucous layers. They generally arise by the enlargement and
blending together of several vesicles placed near one another. In
their duration, and in the changes to which they are liable, bullae
correspond exactly to vesicles.

(8.) Pustules {Pustula, Pusteln) — "Vesicula, quce pus fert, est
pustula,^' was the definition given to this form of eruption by our
forefathers. Thus, the purulent yellow character of the contents of
an elevation of the cuticle distinguishes a pustule from a vesicle.
At the present day we read as the definition of a pustule that it is a
small abscess, covered only by epidermis ; and both this statement
and the former one are equally correct,

A straw-colour is the fundamental tint of pustules, for the puru-
lent fluid which they contain is a condition, si?ie qua non, of their
existence ; but the pus may be mixed with more or less blood or
sebum, which causes them to appear in the one case of a darker,
in the other of a paler, yellow colour.

Yarieties in their size and form gave "VYillan, as is well knowTi,
occasion to describe several kinds of pustules. At the present day
one is not inclined to attach any great importance to these distinc-
tions ; but I think it well to introduce them here for this reason,
that one can by these special denominations most simply indicate
the size of a pustule in any particular case. Omitting the Phlyctis,^
which must be referred to the vesicles, there remain three forms of
pustules, namely, the Achor, the Psydracium, and the Phlyzacium.

By the achor is understood a round pustule, the size of a millet-

1 ' Die Hautkrankbeiteii und Hire Beliaudluug systematisch beschrieben,' von
Robert Wiilan, &c. ; aus dem Englischen, von Fr. G. Priese, p. lo, Breslau,
1799.

In the English work ' On Cutaneous Diseases ' (vol. i, Introduction, p. 13),
Willan mentions the Plilyzacium, the Psydracium, the Achor, and the Cerion,
or Pavus, but not the Phlyctis. — [Ed.]

16 GENERAL SYMPTOMATOLOGY.

seed, scarcely or not at all elevated above the surface, and generally
perforated by a hair. It is observed chiefly on the hairy scalp
and on the face. By drying-up of the pus contained in it, there is
generally produced a rough, granular, honey- coloured crust, of
which the joeculiar appearance is probably due to the admixture
of sebum with the pus. "Willan introduces the Favus or Cerion as
a species of this affection, starting from the notion that the Favus
(Tinea favosa seu lupinosa) arises from the desiccation of this kind
of pustule. This however, as is well-known, is not the case.

The psydraceous pustule frequently begins as an achor, but when
fully developed, is of greater size and contains a larger quantity of
pus. Its margin is not circular, and is surrounded with a red
areola. It dries up into crusts which have a more or less green
colour. It is met with chiefly on the limbs.

The term phlyzacium is applied to pustules which are of at least
the size of a pea, and which are semi-globular, and therefore have a
circular base. They are filled with pus mixed with more or less
blood, form brown or black crusts, and, like the psydracium, occur
only on the limbs.

With reference to the umbüicus, it may be remarked that hi each
of these forms this central depression is present only at the com-
mencement of the pustule, and always disappears during the course
of its development. For as the quantity of the contained fluid in-
creases, the roof of the pustule becomes stretched; and thus the
processes of epidermis by which the umbilicus is formed, and which
are connected Avith the rootsheath of the hair, become softened and
broken down.

Besides these forms which have received names, pustules offer
many other varieties. Thus when they are developed from other
kinds of eruptions, such as papules or tubercles, their base presents
a more or less hard, red infiltration, which was termed by Fuchs, a
fleshy pericarpium (Fleischiges pericarpium) .

The seat of pustules is of course always beneath the horny layer
of the cuticle; but with regard to their being superficial to the
corium, or more deeply situated within it, many differences prevail.
It must not however be overlooked, that those which are developed
from papules or vesicles, will naturally occupy the same position as
the eruptions which preceded their formation.

The pathological process, which produces pustules can essentially
be no other than that of suppuration. The element« of pus (element-

SECONDARY FORMS OF EFFLORESCENCE. 17

aiy granules^ nuclei^ and nucleated cells), in fact, develope them-
selves in those exudations which lie beneath, and are covered only
by, the epidermis, just as they do in other exudations, wherever they
may be deposited. And this applies equally whether they showed
themselves at first as points (Stippen), or as papules, tubercles,
tumours (Knollen), vesicles, or blebs. Thus then pustules are
among the forms of efflorescence, which for the most part arise from
pre-existing eruptions of a diiferent character, and they therefore do
not strictly deserve the name of primary symptoms, of which the
distinguishing mark is that they are caused directly by the original
morbid products. As, however, the exudation which precedes the
occurrence of suppuration beneath the epidermis frequently escapes
notice till it becomes converted into pus and thus betrays its pre-
sence by its yellow colour, it often happens that pustules are the first
perceptible morbid appearance, and hence one cannot help admitting
them among the primary affections.

II. — Secondary Symptoms or Forms of Effiorescence.

As has been already stated, we understand by this term (Secundäre
Krankheitserscheinungen) those pathological appearances which are
generated in the tegumeutary tissues, not as a direct result of the
disease, but by the metamorphosis, the softening, or the desiccation,
by the breaking down, the fissuring, or the ulceration, or again by
the organization of the morbid products deposited in the skin. The
following are the appearances which fall under this head.

(i) The excoriation {Excoriatio, Hautabschürfung, Oberhautab-
schürfung) presents the following characters, which also distinguish
it from the ulcer. The epidermis, or at any rate the horny layer of
it, is destroyed ; either the rete mucosum, or the corium, of which
there is no loss of substance, is exposed ; and, lastly, healing occurs
without the formation of a cicatrix.

The appearances by which excoriations manifest themselves vary,
according as they follow pre-existing eruptions, or are caused by a
direct destruction of the epidermis. In general, they show them-
selves as red shining spots, more or less moist or bleeding, of which
the margins are sharply cut off from the normal epidermis which
surrounds them. These sometimes at once skin over, becoming first
covered either with a brown pellicle arising from dried blastema, or

GENERAL SYMPTOMATOLOGY.

with a reddish-black crust formed from blood. In other cases they
persist for a long time in an unaltered condition, constantly pouring-
out fluid and remaining moist.

The excoriations which are consecutive to pre-existing eruptions
present fresh varieties, according as they arise from the destruction
and rupture of vesicles, blebs, or pustules, or are caused by the
loss of the epidermis which formed the covering of papules, tuber-
cles, or wlieals. In the former case they are more extensive, and
are generally circular or discoid in form. They are also sharply
limited by a border of healthy epidermis ; and they do not bleed,
but are covered merely by a more or less fluid layer of blastema.
In the latter case, they are punctiform, or at least not bigger than a
lentu, and of a round or elongated form ; and they are either still
bleeding, or bear a scab formed from dried-up blood.

Excoriations, which are caused by the loss of epidermis from
parts of the skin previously healthy, resemble in many respects
those just described, but are generally of larger extent; and the
crusts which cover them have for the most part a greater thickness.

From the appearances which we have been describing, and from
the part of the body which is affected, one is almost always able iu
an mdividual case to indicate precisely the nature of the causes
which produced excoriations. Tor in general they occur only where
the horny layer of the epidermis has been separated from the mucous
layer by exudation taking place heneath it, or where the cuticle has
been torn from the corium or from the rete Malphigii by injuries
mflicted u2ion it. In the first case the excoriation is preceded by an
eruption, and the appearances already described manifest themselves.
In the other case it is found upon otherwise healthy skin, and owes
its origin to friction, to pressure, or to scratching with the finger
nails.

(2) The cutaneous ulcer {Ulcera cutanea, Hautgeschwüre) is a
term applied to a loss of substance of the corium which is caused
by past disease of the skin, and in which the restoration of the
tissue destroyed is either not taking place at all, or is going on very
slowly, because the blastema which is thrown out does not possess
the requisite properties.

The points which require observation in an ulcer are its seat, that
is, the part of the skin at which it occurs ; the condition of its sur-
face, of its base, and of its edges ; the state af the integument
round it ; the quality of the fluid which it secretes j and its subjective

SECONDARY FORMS OP EFFLORESCENCE. 19

symptoms ; wlietlier^ that is, it causes paiu, or is, on the contrary,
insensible.

In reference to their form and configuration, it may be remarked
that ulcers present very great varieties, according to their position
and their duration, the nature of the process which gave rise to
them, and the various injurious influences which have acted upon
them. The indication of these differences is, indeed, provided for
by the terms Ulcera cniris, s?/j)/iilitica, c/iro/iica, inchrata, mveterata,
&c. But these expressions refer to nothing more than the acci-
dental condition of the sore, and are in very few cases to be
regarded as names of distinct affections, possessing specific characters.
To this, however, the syphilitic ulcer is an exception.

(3) Fissures {R7ia(/ades, Rhaffcidia, Rimoi cutis, Hautschrunden)
are elongated aud usually linear cracks m the skin, which may affect
either the cuticle alone, or the corium also, and which are some-
times dry, sometimes attended with an oozing of formative fluid,
or of blood. They arise when the skin is the seat of infiltration, or
is abnormally brittle, in parts (such as the fingers, elbows, and
knees,) which are liable to much stretching or dragging.

(4) Scales {Squama, Schuppen). These are plates of dead epi-
dermis of various size, which, in consequence of morbid conditions
of the skin, have become partially or altogether detached and cast
off from their bed.

Their form, size, thickness, compactness, and colour, are subject
to many variations. They maybe either flat or raised; they may
be merely like dust or bran, or they may be as large as the palm of
the hand, or they may copy the form of parts of the body, as, for
example, of the fiugers. Some are as thin as goldbeater's skin;
others are many lines thick ; sometimes they are soft and flexible, at
other times they are dry and brittle. Lastly, they may have the
same colour as the rest of the epidermis; or they may be white,
yellow, brown, green, or black.

The process which gives rise to desquamation of the epidermis
may affect tracts of skin of very variable extent. When it is an
independent disease, that is, when it is preceded or accompanied by
no other discoverable cutaneous affection, it is termed a pityriasis ;
whereas the same appearance receives the name of desquamation
{Desquamatio, Abschuppung) when it is the result of a previous
disease of the skin. Moreover of this last, certain subdivisions are
recognised* There is the Desquamatio furfur acea^ when the scales

20 GENERAL SYMPTOMATOLOGY.

are small^ and resemble meal or bran ; the Desquamatio memhrauacea,
when the cuticle becomes detached in large membranous pieces ; and,
lastly, the Desquamatio siloquosa ; a rare appearance, in which sac-
cular elevations of the epidermis are formed by the exudation of
fluid beneath them, which elevations persist as empty shells, after
this fluid has escaped or has been absorbed.

(5) Crusts [Crustce, Krusten, Borken, Grinde,) are those soHd
masses which are formed as a result of disease of the skin, by the
drying up of exuded fluids, or of extravasated blood. They pre-
sent many different appearances, according to the causes which give
rise to them. Thus, serous exudations produce by their desiccation
merely flat brown scabs ; whilst sebum by itself, or in admixture
with pus, always dries into yellow crusts, resembling honey or gum.
Again, those which are formed from pus alone, have a green hue,
which is changed by the presence of blood, into a brown, or even
into a black colour.

The thickness or height of a crust depends partly on its duration,
and partly on the rapidity with which the exudation which gives
rise to it is poui'ed out. In general, crusts become more elevated
in proportion as their formation is slow and of long duration,
while exudations, which take place rapidly, produce but thin scabs.
Some crusts are flat ; others are raised or even conical ; and some-
times they may be observed to have a conchoidal, scutiform, or
alveolar appearance.

(6) Lamellated crusts {Crusta lamellosce, Schuppengrinde). As
their name implies, these occupy an intermediate position between
scales and crusts. They consist of layers of epidermis and of dried
sebaceous secretion or inflammatory exudation, placed one over the
other in strata, so that there is no great difference in the proportion
of their component parts. They are easily recognised by their flat
appearance ; by the colour of their surface, which is, for the most
part, whitish-yellow ; by their laminated structure, and by the differ-
ences in the colour of the individual layers.

Their occurrence is limited to those cases, in which small quan-
tities of sebum or of exudation are deposited at the same spot, at
regular intervals, between which the epidermis has time to repro-
duce itself beneath the effused matters.

Examples of Crusta lamellosa, are afforded by the flat layers of
sebum, from a pale yellow to a black colour, which are found on
the scalps of children who are not kept clean ; by the similar appear-

SECONDARY FORMS OF EFFLORESCENCE. 31

ances in SeborrJicea capillitii, and by the yellow or brown thin plates
which occur in Porrigo scutulata [Herpes tonsurans.)

(7) Scars [Cicatrices, Narben) are the structures which replace
portions of skin which have undergone destruction. They are dis-
tinguished from the healthy integument by their greater hardness,
by their smooth, shiny aspect, and by the absence of pigment, of
hair, and of glandular openings upon their surface.

Thus the growth of new tissue, which gives rise to cicatrices,
makes up for the loss of substance in the skin only by regenerating
its fundamental structure, the connective-tissue elements. The other
tissues w^hich are peculiar to it, the papillpe, the hairs, and the seba-
ceous glands, are not restored by this process.

The peculiarities in the form of certain scars depend less on the
nature of the morbid process which caused the loss of substance,
than on the circumstances which attended the cicatrisation. Hence
it follows, that a cicatrix presents no positive marks from which
one can with certainty draw conclusions as to the past disease
which gave rise to it. In other words, there are no characteristic
cicatrices. A scar may present the same smooth appearance whether
it arose from an ulcer, a wound, a burn, or a scald, or from the
application of some corrosive agent, provided only that the healing
process was not accompanied by the formation of connective-tissue
in excess, or that the resources of medical science kept this within
proper limits. On the other hand, precisely similar injuries may
lead to raised, prominent, cord-like, radiating, or funnel-shaped cica-
trices, and for this some peculiarity of the loss of substance may be
answerable ; or it may be the result of cicatrisation occurring (either
spontaneously or from bad management,) without the uniform de-
velopment of granulations.

Varieties in the colour of cicatrices are caused by their age.
Those which are quite recent have, for the most part, a pale red
surface, and the blood-vessels which they contain may frequently
be seen through the cuticle in the form of red serpentine lines. Old
cicatrices sometimes contain pigment, sometimes have a perfectly
white, shining appearance.

As for the subjective symptoms to which they give rise, most
cicatrices are less sensitive than the healthy skin ; but, on the other
hand, there are some which are extremely j^ainful.

22 GENERAL SYMPTOMATOLOGY.

III. — 0)1 the Distribution of Eruptions over the Skin.

The forms of efflorescence, primary and secondary, which we have
described in the preceding section, present many varieties in their
mode of spreading and distribution, from which the affections to
which they belong derive various peculiarities in their (Zeichnung)
pattern.

These peculiarities (Zeichnungen) have been regarded as standing
in a causal connection with the essential nature of the affection :
and they have been used as names for species of diseases of the skin,
whue the genera were based on the form of the primary efflores-
cence. Thus, dermatologists were of opinion that changes in the
mutual relations of the elements of an eruption were associated with
alterations in the nature of the disease. In this they took for an
example the case of plants, in which differences in the position of
the leaves and flowers do, of course, characterise different species of
the same genus. The comparison is, however, a bad and unsuitable
one; for, in diseases of the skin, the mutual relations of the parts
of an eruption are, in fact, sometimes quite accidental, and therefore
variable : and sometimes they are dependent on laws which are very
different from those which these writers regard as determining
them. If we endeavour to ascertain these laws, we find the
peculiar pattern of certain skin affections to arise partly from
the anatomical arrangement of the cutaneous vessels and nerves,
partly from the way in which these diseases spread, per contigiinm,
from one point to another. But these conditions are very far from
explaining all the peculiarities in the mutual relations of tlie parts of
an efflorescence ; and, m most cases, we are obliged either to attri-
bute them to chance, or to confess freely our ignorance of the laws
which produce them.

If we attempt to attach more distinct conceptions to the different
names employed by authors to designate the appearance and outline
of cutaneous diseases, we arrive at something like the following : —

Every efflorescence, whatever may be its form, consists of ele-
ments (which may of course have different characters, and do not
necessarily resemble one another), ^vhich either stand each by
itself, surrounded by healthy skin, or touch and blend with one
another, and thus undergo modifications in their original form,
which may even be alfogether lost. Thus, then, all eruptions may

DISTRIBUTION. 23

be divided into tliose which are distinct {Efflorescentiee discretce),
and those which are confluent {Ef. confertd).

These names, however, are not the only ones which are used to
indicate these characters. We find in books the epithets solitaniis,
sparsus, intertinctus, dissemhiatus, pimctatiis, guttatics, monocarpus,
&c. All these have the same signification as the word discretus, and
therefore we regard them all as synonymous with it. And again, the
terms confluens, aggregates, diffusus, have exactly the same meaning
as confertus, when used of diseases of the skin.

It is, however, very different with those designations which are
used to indicate the special features of an efflorescence (die besondere
Krankheitsbilder). Thus, the term corymhosus is applied to those
eruptions which form groups, such as herpes. The names orbicii'
laris, circinatus, centrifugus, and ammlatus or anmilans, to those
which are arranged in circles,^ as in psoriasis, roseola, erythema, &c.
The epithet iris belongs to that morbid appearance which is distin-
guished by concentric rings, or by a circle of which the centre is
itself the seat of an efflorescence. Instances of it occur in herpes,
erythema, &c. The terms gyrus, gyratus, are applied to segments of
circles, Mdiicli are found either singly, or in groups, so as to have a
serpentine arrangement; they are observed in psoriasis, erythema,
&c. The same appearances receive the epithet serpiginosus when they
belong to ulcers, or to elevated growths of new tissue, such as
lupus, or the syphilitic serpiginous ulcers, &c.

Discus (Scheibe), discoides, nummularis, are terms given to those
eruptions of which the appearance is like a coin, or a flat round
plate, and the designation scutulatus, scutiformis, is applied to those
forms of skin-affection which, though round, are not discoid or
nummular, but shield-hke or saucer-shaped, that is to say, excavated
in the centre. Examples of this are found in favus, psoriasis, &c.

The term circ^miscripUis, agaui, is used of those affections whose
margins appear on all sides sharply cut off from the adjacent healthy
skin. Marginatus, on the other hand, is employed when such a

1 It would be very desirable to indicate by distinct names, the differences in
the nature of these circles. For some of them are caused by the arrangement
of the individual elements of the efflorescence, which form a ring round an
imaginary centre ; and for these circles we would use the epithets circinns,
clrcinaUis; while the names annuhis, unmdatus, annularis, would serve for
tliose which are developed from round discoid eruptions, which get well first at
their centre, and thus lead to the formation of rings,

34 GENERAL SYMPTOMATOLOGY.

defined border does not surround the whole of the efflorescence, or
even when it is observed only at one extremity of it, while the oppo-
site end becomes gradually pale, shades off into healthy skin, and, to
use a common expression, seems as if "washed out" (wie verwaschen) .
Maculated rashes (fleckige Röthungen), that is to say, red patches
alternating with parts of the skin which present the normal colour,
receive the e^iithet variegatus, in contradistinction to those which
afPect the skin uniformly, and for which the name lavigattts is used.
The appellations j%2«'ö(if?/.s', agrhis, answer to no definite characters,
but are applied by difi^erent authors arbitrarily, now to one, now to
another form of cutaneous disease.

Certain of these epithets, again, refer to the form or to the colour,
or to some other feature of the cutaneous disease, merely as it exists
at the time. Such are the terms inveteratus , acwniuatns, verrn-
corns, mucosus, granulatus, himidus,fungosiis, exuherans, excoriicans,
rodens, exedens, sordidus, lactißtms, madescens, siccus, microcarpus,
macrocarpus, amiantaceiis , prominens, lenticidaris , miliaris, tuherosus,
favescens, nigricans, melanodes, alhidus, ruber, amorphus, crystallinns,
eoniformis, glohulosus, pempihigodes, fimbriatus, suberinns, achatinus,
eschar oticus, &c. There are others which relate to the age and sex
of the patient, such as neonatorum, infantilis, puerilis, adultorum,
senilis, virilis, muUebris, Others, again, indicate particular re-
gions of the body, as capillitii, faciei or facialis, larvalis, cervicalis,
mammarum, pectoralis, abdominalis^ extremitatum, brachialis, 2^o-l-
maris, femoralis, plantaris. Moreover, some liave reference to the
duration of the disease, TiS fugax, ephemerus, acutus, chronicus, vola-
iicus, perstans. And others relate to its geographical distribution,
such as septentrionalis, tropicus, Aquitanicns, Asturiensis, Lombardi-
cus, Bothnicus, Esthonicus, Sibiriens, &c.

All these terms have for us no greater value than is implied by
the sense of the words. They may pass as means of defining with
greater precision the more or less accidental (and therefore not cha-
racteristic) appearances which an eruption presents at the time ; but
they are not to be used (as was done by Willan, and by all those
who have followed his system, with or without modification) as names
for the different species of a genus. In the natural history of mine-
rals, of plants, and of animals, such terms are ajiplied in this way,
and are rightly so applied; and it was from this source that the
older dermatologists, who compared the different cutaneous eruptions
to flowers and fruits, derived the principles of the nomenclature

DISTRIBUTION. 25

which they adopted for diseases of the skin. But they certainly
made a mistake in doing so.

We do not, then, set the same vahie as our predecessors and con-
temporaries on the usual denominations of dermatoses, in which a
specific as well as a generic name is invariably employed. On the
contrary, in naming a skin-affection, we content ourselves with the
use of a single appellation, unless we consider the addition of an
epithet necessary to define more accurately the nature of the disease.
"VYe adhere, in fact, in this respect, to the nomenclature which is
now generally employed for the other diseases of the human or-
ganism.

Por similar reasons, we must protest against giving a general name
to any cutaneous disease, merely because its presence is confined to
a particular part of the skin ; for each cutaneous affection may appear
on any part of the surface of the body which presents the anatomical
conditions necessary for its development. And therefore, to give to
a disease a name derived from its seat alone is inadmissible ; and the
terms Tinea, Forrigo, Crnsta lactea, Meniagra, Pygagria, Pahnaria,
&c.. should be transferred to the domain of history.

CHATTER II.

ON THE DIAGNOSIS, ETIOLOGY, TREATMENT, AND CLASSIFI-
CATION OE CUTANEOUS DISEASE IN GENERAL.

I. Diagnosis.

For the recognition of a disease of the skin, no other assistance is
required than a knowledge of the objective symptoms, which are
visible on the surface of the bod}^ in each particular case. We
do not attach any value whatever, either to the history or to tlie
subjective phenomena in investigating a cutaneous affection ; for we
ought to be guided in this matter only by those symptoms which
are appreciable by the sight, the touch, or (sometimes) by the smell.
These afford certain and infallible grounds for the establishment of
a diagnosis, for they have their origin in the malady itself. They
are, so to speak, the alphabet, of which the letters are traced on the
skin ; and our task is but that of deciphering the writing.

To accomplish this, it is pecuharly important to have a method
in the investigation of every skin affection, and not to neglect certain
rules in examining the cutaneous surface when diseased.

Above all, the whole of the body should be looked at, even in
cases in which the malady is nominally or really confined to one
particular spot ; for it frequently happens that the disease (das
Krankheitsbild) assumes quite a different aspect when regard is paid
to the appearances presented by every part of the surface, from what
it would have if those spots only were examined which were indi-
cated by the patient as its seat. By attending to this rule, one is
often enabled to find very different and much more rehable grounds
for the diagnosis of cutaneous diseases than could be obtained in any
other way.

It must not be objected that an examination of this kind, though
it may do very well in a Hospital, cannot be carried out in private
practice, and especially in the case of female patients. It is quite a
mistake to make this assertion. In the first place, decency should

DIAGNOSIS. 37

never be disregarded, even in Hospital practice ; and by us at least,
no procedure is adopted, at which decorum or modesty could take
offence. It is quite unnecessary to conduct an examination of the
skin, so as to cause any discomfort to the patient. The principal
parts of the body should be looked at in succession, and in their
anatomical order; the genitals and the breasts should be left un-
touched; or where this is impossible, their inspection should be
deferred to the last ; and then all patients will submit readily to an
examination which is undertaken for their own benefit. Again full
day-light, and sufficient illumination are indispensable to the
thorough observation of the skin's surface. However brilliant an
artificial light may be, and whether derived from candles, lamps, or
gas, it always gives the skin, whether healthy or diseased, a different
appearance, and generally makes it look paler than by day-light.
Another point, which may be of considerable importance in ex-
amining a cutaneous affection, is the warmth of the air ; for both the
higher and the lower degrees of temperature modify the colour of
the surface. The ordinary temperatui'e of rooms (66° Fahr.) is the
most proper. For the same reason one should avoid making the
diagnosis of a skin disease, either during or just after the employ-
ment of a cold or warm bath by the patient.

Due regard being paid to these considerations, the examination of
the case may be commenced, and in doing this, our object is not, as
might be supposed, to endeavour to find some real or imaginary
primary efflorescence, but rather to keep to the general appearance
of the disease (das Gesammtbild), not allowing ourselves to be
beguiled by any special symptom, however striking it may be.
The following are the chief points which require to be noticed.

(i) In regard to the surface of the skin, it must be observed
whether this is smooth, soft, even, with a greasy lustre, and free
from crusts or scales, — or whether it is harsh, ready to crack,
uneven, dry, and covered with scales or scabs. It has also to be
noted whether the natural lines and furrows are too shallow or too
deep, too near or too widely separated from each other ; what is the
condition of the pores of the skin, whether or not they are plainly
visible, and whether pervious or obstructed; and lastly, whether
the growth of hair is normal, excessive or deficient. For these
various circumstances enable us to draw certain conclusions as to
the pathological changes in the different tissues which form the
skin.

28 DIAGNOSIS.

Thus the healthy integument is smooth and soft to the feel^ and
has a sHght greasy lustre ; and the shedding of its epidermis goes
on without visible desquamation. The hnes and furrows which
exist on its surface are moderately pronounced, and are about a
millimetre apart. The apertures of the sebaceous and sudoriparous
ducts, or the cutaneous "pores," as they are called, are at some
parts not to be seen, while elsewhere they may be observed as
slight depressions about two millimetres distant from each other.
The amount of hair varies with the sex, and also according to the
colour of the hair itself, but keeps within certain limits both as to
quantity and quality.

On the other hand, when the epidermis is developed abnormally
the surface of the skin may be rough, uneven, diy, chapped, or tra-
versed by fissures, and covered with scales of various colours and
thickness (as is the case in pityriasis, ichthyosis, prurigo, &c.). The
lines and furrows also may be abnormally deep, and separated from
another by hypertrophic papillse to a distance of two or three mil-
limetres. Again, the openings of the follicles may be plugged with
sebum, and dilated (as in seborrhsea). Lastly, the hairs may fall
out or may be imperfectly developed ; or on the other hand, they
may be unusually thick, and may be present in increased numbers.

(2) Again it has to be considered, with reference to the colour
of the skin, whether the pigment is excessive in amount, or
deficient, and whether it is irregularly distributed; whether the
surface is abnormally red, either in its whole extent or in patches ;
or whether lastly it deviates from the healthy colour in the direction
of too great pallor.

Thus, in respect of the pigment contained in the skin, it has to
be noticed whether this is uniformly distributed, or is confined to
particular spots, of greater or less extent ; whether the pigmentation
corresponds to that of the race of men to whom the individual
belongs, and to his age, sex, residence, and occupation, as well as to
the colour of his hair, the season of the year, &c. ; or whether there
is any deviation from the normal condition in these respects ; and
further as to the intensity of the pigmentation, whether the epider-
mis has merely a yellow tinge, or is of a brown or dirty-black hue.
Again the pigmentation may be defective, either universally or in
parts of the surface. And in this case we have to consider whether
besides the partial absence, there is not also at other points an
excess of pigment. Lastly, it is to be observed whether the tracts

DIAGNOSIS. 29

which present these appearances are bald, or are on the contrary
covered with hairs of a dark or white colour, corresponding to that
of the surface on which they grow.

Now it is extremely difficult, to establish a norm for the
pigmentation of the skin of a healthy person, for this is liable to be
modified by many circumstances. But at least this much may be
said, that the normal skin of individuals of our own (that is, of the
Caucasian) race, generally displays an uniform pale chamois colour,
and that a darker tint is observed only at certain points, such as the
nipple, the labia pudenda and the scrotum.

Accordingly all irregular coloration must be regarded as morbid,
whether it is circumscribed or diffused, and whether the skin is
darker or paler than it should be, whether bald or covered with
hair. This applies to cases of the so-called Lentigines, Ephelides,
Chloasmata, Nävi sjnli et verriicosi ; and also to the Viiiligines, the
Ac/iromasia, &c.

The same thing may be said also of all colorations and discolora-
tions (Decoloraiiones, Byschroynasice) in which there is any consider-
able deviation from the normal tint of the skin, even though the
morbid condition is uniformly distributed over the whole surface of
the body.

As to the cases in which the skin presents a red coloration, this
of course either depends on the capillaries being more or less injected,
or it arises from extravasated blood. The ])ressure of the finger is
employed to settle this question. If the redness disappears on the
application of pressure, which can of course be ascertained only
after removal of the finger, this is a proof that the blood has not
escaped from the vessels, but is merely retarded in its course and
accumulated in the cutaneous capillaries. To this condition, as is
well-known, the terms Hyperamia and Stasis are applied. If, on the
contrary, the red spot retains its colour without alteration, however
forcible the pressure which is brought to bear upon it by the finger,
the redness then arises from extravasated blood, and thus the proof
that hsemorrhage has occurred, is established.

RemarJc. — Beyond the determination of this point, namely, whether
the reddening of the skin is caused by hypera3mia or by haemorrhage,
we derive no further assistance in diagnosis from the application of
pressure by the finger. For we have been unable to find any con-
firmation of the statement made in almost all medical works, that
when the pressure is removed the re-appearance of the red colour

30 DIAGNOSIS.

takes place^ sometimes from the centre towards the periphery,
sometimes from the periphery towards the centre. This must either
be simply a mistake, or must depend on differences in the form of
the surface and in the mode in which the pressure M'as appKed.
For if a flat yielding surface, like the inside of the thigh, be pressed
on by a hard convex body, such as the finger-tip placed vertically,
the centre will, of course, be subject to greater compression than the
periphery. Now the more forcible the pressure on the cutaneous
vessels, the longer will be the time requhed for them to fill again
with blood. Hence the redness will reappear first at the periphery
(which received least pressure), and last at the centre (which was
the most compressed) ; in other words the redness will return from
the circumference to the centre. The same thing will occur when a
hard convex surface, like that of the thorax is pressed on by one
which is yielding and flat or nearly so, such as the pulpy extremity
of the finger. And on the other hand, pressure on a concave
surface like the groin, by means of a flat one, will necessarily affect
the periphery more than the centre ; and in such a case the redness
will re-appear in the centre first, and later in the chcumference.

(3) Attention must next be devoted, in the investigation of
cutaneous affections, to the size of the part, and to the thickness
and degree of infiltration of the cutis.

Changes in the size of any tract of the skin cannot readily
escape observation when looked for, particularly if they are not
symmetrical, for we can then always find a standard of comparison
on the opposite or healthy side of the body. To ascertain the thick-
ness of the cutis, the best method of proceeding is to raise the skin
into a fold, and to compare the transverse diameter of this either
with that of the corresponding part on the opposite side of the
patient, or on a healthy person. In this way the degree of infiltra-
tion of the skin may also be estimated.

(4) Next, and most important for diagnosis is the appreciation of
the appearances produced by the scratching of the patient. One
becomes in this way quite independent of the statements of the
patient as to the subjective sensations of itching; for no one, who
does not really itch, will scratch himself to any extent. And apart
from this advantage, an accurate acquaintance with the phenomena
to which the irritation of scratching gives rise, affords positive or
negative assistance w-hich is of the greatest value in diagnosis. For
we know that certain diseases such as scabies, eczema, prurigo,

DIAGNOSIS. 31

and urticaria are always, and that others, as for example the
syphilitic eruptions, are never attended with itching. And we are
thus able to exclude altogether either the one or the other of these
groups of diseases.

In order to give an exhaustive description of the excoriations
which are produced by scratching, and chiefly by the finger nails, we
have to distinguish certain varieties of them according to the degree
in which the various tissues of the integument have been injured
or have undergone pathological changes, and also according to the
intensity presented by these appearances.

Under the first head, we have to remark, that the participation of
the papillge, in the form of hypersemia of their vessels, is shown by
the presence of red striae, or of difi^used redness (Erythema urticans).
The follicles also become swollen by exudation in their periphery,
and produce elevations above the surface, which take the form
either of red papules (Lichen urticatus) or of wheals (Urticaria
subcutanea). Repeated scratching gives rise to exudation on a
larger scale, which penetrates between the layers of the cuticle.
This next becomes raised ; vesicles with or without a red periphery
or base make their appearance; and an Eczema is developed. Or if
the contents of the vesicles become purulent, they then form
pustules of various sizes, and thus constitute an Ecthyma.

The effect of the scratching on the epidermis is either to lacerate
it and to tear it to a greater or less depth away from its bed, in
other words to produce excoriations ; or merely to make the skin
assume a darker colour, from increase of pigment.

In reference to these excoriations, we may be allowed to ^ establish
three grades of them, which, being produced by the different degrees
of force employed in scratching, enable us to draw inferences as to
the intensity of the itching. When this is slight (Titillatio) the
scratching is also inconsiderable, and neither long-continued nor
often repeated. Hence the most superficial hard layers of the
cuticle are alone injured by it, and become detached in the form of
mealy dust, or of bran-Uke scales from the deeper strata, which still
remain adherent. Itching of the second degree ( Formic atio) , on the
other hand, being more intense leads to a severe and more protracted
scratching ; and by this the whole of the horny layers of the cuticle
is violently torn from the rete mucosum, of which the red moist

^ 'Zeitschrift der k. k. Gesellschaft der Aerzte.' Jahrg., 1846; i Band.j
p, 332, et seq.

32 DIAGNOSIS.

surface is exposed. The consequence of tliis is that the blastema,
which is poured out by the papillae for the production of epidermis,
dries into a thin yellowish-brown firmly-adherent scab, just as we
see a similar scab formed after the application of a blister. In the
third and most violent degree of itching (Pruritus) which of course
involves an incessant rubbing and scratching in which great force is
employed, not only is the epdermis quite torn away from the
corium, but this itself becomes injured. The minute vessels of the
papillae are lacerated ; haemorrhage takes place ; and by the drying
of the drop of blood which is poured out, there is formed a reddish-
brown or black scab of greater or less size.

The phenomena which we have been describing are those which
are observed when the scratching is practised on a skin which is not
diseased. They, of course, present somewhat different features when,
simultaneously with the itching, there exists also some other morbid
change in the skin. It is scarcely possible to give a general sketch
of the morbid appearances which are then produced ; but this much
may with confidence be asserted, that eruptions which are elevated
above the cutaneous surface will always be the first to be attacked,
and will often be partially or completely destroyed, by the agency of
the fingers in scratching, and that the intervening tracts of skin will
come in for their turn only when the parts which were covered by
the eruption have been brought to the level of the integument.
Hence it is explicable that in prurigo the papules, in eczema the
vesicles, hi psoriasis the separate red patches, with their coverings
of scales, are the points which first show the effects of scratching,
although the patient tears away at almost all parts of his skiu, with-
out selecting any particular spot.

As for the deposits of pigment which are the result of scratching,
it may be noted that these have a direct relation to the intensity
of the itching. This can be most clearly demonstrated in scabies,
eczema, and prurigo, in which affections no abnormal dark colora-
tion of the epidermis is at first to be observed. In fact, these
pigmentary deposits appear only during the progress of these dis-
eases; they advance jsöfr^^;«^^« with the increase in the excoriations,
and they are to be foujid only at those parts where the patient
is constantly scratching liimself.

(5) ^^6 have now only to direct our attention to the other symp-
toms which have not as yet been referred to. Eegard must be paid
to the form, the number, the arrangement, and the position of the

ETIOLOGY. 33

primary and secondary symptoms, which have already been described.
We must endeavour to ascertain what pathological process lies at
the bottom of the existing cutaneous affection ; what injurious in-
fluences have been in operation upon the healthy or diseased skin ;
what are the age, the sex, and the occupation of the patient ; what
has been his mode of life, and how he has been fed, lodged, and
clothed. Our object must, in fact, be, as we said at first, to take a
broad view of the case as a whole. An accurate diagnosis will with
much more certainty be arrived at by the investigation of these
various points than by searching merely for an accidental (jeweihg)
primary efflorescence.

II. — Miology.

The causes Avhicli give rise to diseases of the skin are partly
such as are internal and rooted in the organism itself, partly such
as are external, and by which the integument is alone, or at least
primarily or chiefly, affected. Dermatoses, therefore, have long been
divided, in reference to tlieir etiology, into the symptomatic (uni-
versal, deuteropathic, dermajwstases and dermexantheses) , and into
the idiopathic (protopathic, local, dermatonosei) .

In regard to the first of these groups, the opinion was entertained
that a common cause lay at the foundation of all, or at any rate of
most, skin-affections, which was sought for in a special change in
the composition of the juices. This condition was supposed to
give rise only to cutaneous diseases, and was known as the Bj/s-
crasia herpetica : but as its existence is extremely problematical, and
as no evidence of it has as yet been brought forward, we do not feel
called upon to admit it.

We do, however, know that some affections of the skin are so con-
nected with certain maladies which have been shown to be blood-dis-
eases, that we cannot but regard them as the effects of those diseases.
We have examples of this in the acute exanthemata, in variola, mor-
billi, scarlatina. There are also the rashes which occur in typhus,
consisting of papules, of spots {roseola, purpura), or of vesicles
(miliaria). Again, in cholera, cutaneous affections are observed as
maculse (roseola), or as tubercles (erijthema papulatum et tubercu-
latujn) ; in albuminuria, as purpuric spots, as pruriginous papules,
and as cßdema ; in uraemia, as sebaceous secretion, containing urea
and uric acid — the so-called uridrosis ; in pyaemia, as erysipelas,
dermatitis, imptetigo, and in the form of pustular and furuncular

34 ETIOLOGY.

eruptions ; in cliolosis^ as a yellow or brown coloration of the skin ;
in chlorosis, as sallowness and pallor, with infiltration of serum into
the integument. In fact, in all these conditions, as well as in syphilis,
scorbutus, scrofulosis, tuberculosis, the cancerous cachexia, &c., with
their manifold and complex symptoms, blood-diseases are associated
with changes in the skin.

Moreover, diseases of particular systems and organs are wont
sympathetically to involve the integument. Thus affections of the
intestinal tract, of the internal sexual organs, of the liver, the spleen,
the kidneys, and of the urinary apparatus, give rise sometimes to
urticaria,, sometimes to seborrhoea, eczema, or acne, sometimes to
various forms of pigment-deposit. Again, diseases of the heart,
blood-vessels, or lungs, produce disturbances in the circulation,
which manifest themselves by increased vascular injection, and by
a bright red or bluish-red coloration of the skin. Lastly, there are
various physiological processes, such as menstruation and pregnancy,
and also dentition, which indicate themselves by appearances of
different kinds, affecting the cutaneous surface. Unfortunately, we
are very seldom in a position to demonstrate the real connection
between the internal affection which causes, and the skin-disease
which is caused. "We see only that they occur together, that they
are intimately related, that they mutually react upon each other.
But we are not at the present day able to show accurately why a
general disease, such as albuminuria, should give rise to a skin-
affection such as prurigo; or why from a disorder of an internal
organ like the uterus should be derived a dermatosis, as, for ex-
ample, chloasma.

Besides these visceral affections, an influence in the generation
of cutaneous diseases is exerted likewise by ordinary injurious
agencies, which arise from the age of the patient, his business and
mode of life, the way in which he is fed and housed, and the cli-
matic conditions to which he is exposed. There are also the different
contagia, of which some present themselves in association with tan-
gible substances, or as inoculable fluids ; while others are only re-
cognised by their effects, and are linked to no solid .or fluid matters.

Hereditary transmission, again, from parents to their offspring
undoubtedly takes place in certain forms of cutaneous disease,
among which are psoriasis, ichthyosis, elephantiasis Grsecorum,
syphilis, &c. The cause of this is, however, to be sought, not always
in a special dyscrasia, but rather in the reproduction in the offspring

ETIOLOGY. 35

of the whole habitus of the progenitor, by which also the fact is ex-
plicable that children have hair of the same colour as their parents,
whether this be light, red, or black. Lastly, diseases of the nervous
system must not be overlooked as the causes of certain dermatoses,
although with reference to this point all accurate investigation is as
yet wanting. One can at most draw negative conclusions, and regard
skin affections which are associated with morbid sensations, such as
itching, pain, w^ant of sensibility, or anaesthesia, as the effect of per-
verted innervation.

In conclusion, we must not forget to mention that even mental dis-
orders and diseases (Gemiithsaffecte, Psychopathien) are said to have
the power of producing certain cutaneous affections, such as urticaria.

Much more potent in the generation of diseases of the skin than
the internal causes which have their seat in the organism itself, are
those agencies which are external to the body, and which affect the
skin directly. Thus are produced the so-called idiojjcitkic dermatoses.
Even among these agents, the effects of climatic conditions, of dress,
and of occupation and mode of hfe, &c., must not be overlooked ;
and, apart from these, there are numberless other injurious influences,
sucli as those of weather — that is to say, of heat and cold, of
dryness and moisture, &c. — which cannot be escaped, being uni-
versal, and affecting everybody in a greater or less degree. But
there are also others among these causes of disease which depend on
conditions pecuhar to the individual. Examples of these are afforded
us by the different arts and trades, in which the skin is often in-
jured by the handling of the necessary tools, by the exposure of the
body to very high or very low temperatures, by the operation of cor-
rosive substances, &c.

Man is often his own worst enemy, for he practises a number of
occupations which subject him to various cutaneous affections ; and
he neglects many of the precautions which would protect his skin
from disease. Thus, one of the chief factors in the causation of the
idiopathic dermatoses is the permanent action of pressure, or the fre-
quent repetition of blows upon the integument, or the constant
friction of some solid body which comes into direct contact with the
skin. And under this head may be reckoned, besides many other
injurious influences, the scratching of patients who suffer from the
itching of cutaneous diseases.

Neglect of the skin, and that sin of omission, want of cleanliness,
are well known to be fruitful causes, from which not a few cutaneous

86 ETIOLOGY.

affections derive their origin. But the same effect may in the end
be produced also by the opposite proceeding, that is to say, by too
frequently repeated or too energetic washing and bathing.

In enumerating the causes which produce cutaneous disease, those
also must unfortunately be mentioned which, no doubt with good
intentions, are employed in the practice of the healing art. As is
well known, the rubefacientia and the epispastica play an important
part in Hippocratic medicine. We are far too lavish with sina-
pisms, vesicants, mezereum, 01. Crotonis Tighi, tartar-emetic oint-
ment (Ung. Autenriethi), and issues. Even the moxa, and the
actual and potential cautery are still too often used. They are
generally applied with the object of effecting (by means of the
powerful irritation of the skin which they produce) a derivation
from some internal organ which is the seat of disease. How
far this end is obtained is uncertain, and opinions about it are
divided. For my own part, I think that the supposed but not
proven good effects of the use of the epispastica are far outweighed
by the demonstrably evil results of their application to the skin.
Daily experience furnishes the proofs of the correctness of this
opinion, with reference to which we shall, in another part of this
work, enter into greater detail.

The epiphyta and epizoa, of which some are met with in the pro-
tective horny tissues — some in the substance of the cutis itself — are
frequent causes of cutaneous disease. The epiphyta, which inva-
riably belong to the class of fungi (Pilze), consist of minute bodies,
which measure from 0*005 — °'°5 niilHrnetres, and are termed
spores {Sporidia, SponiU, Sporen) . They are either naked or enclosed
in special organs {Sporangium, Theca), and they are seated on a
common base (the receptaculum, or conceptaculum) . They reside
either in the epidermis alone, or in the hairs as weD, or, lastly, in the
nails also. The following eight species^ have, up to this time,
been discovered in these tissues :

I. The Tricliophyton tonsurans. Malmsten first found this fungus
in the hair. I demonstrated the fact that it occurs also in the epi-
dermis," in cases of herpes tonsurans.

3. T\\QMi/cocle7'mapUc(BPolonic(E (Günsburg), and the ^n(?^o/?/^y-
ton sjjoruloides (Walther), in the Phca Polonica (Weichselzopf).

' Küchenmeister. ' Die pflanzlichen Parasiten.' Leipzig, 1855, p. 30.
- ' Zeitschrift der k. k. Gesellschaft der Aerzfe,' x Jahrg., 1854, Heft xii,
P- 473-

ETIOLOGY. 37

3. Tlie Microsporon Audoinni (Grubj), in porrigo decalvans.

4. The Microsporon mentagraphyies (Bazin), in sycosis.

5- Tlie Microsporon furfar (Eiclistedi) in pityriasis versicolor.

6. The Ac/iorioti Schoenleinii in favus.

7. The nail-fungus: according to Meissner^ a species of Asper-
gillus; in the Onychomycosis of Virchow.

8. The Oidiiim albicans — on the nipple (Küchenmeister).

The animal parasites which choose the skin as their scene of
action (Tummelplatz) are divided into

I, The Bermatozoa, which cither always, or at any rate during
part of their existence, dwell within the substance of the skin,
and

II, The Epizoa, which merely seek their food upon the skin's
surface, residing either in the appendages of the skin, namelj^ on
the hairs, or in the clothing or other surroundings of persons infested
by these parasites.

To the first class belong

1 . The Acarus scahiei (Krätzmilbe) or itch insect.

2. The Acarus folliculornm (Haarsackmilbe) or pimple-mite.

3. The Pulex penetrans (Sandfloh), the sand-Üea or chigue.

4. The Filaria medinensis (Peitschenwurm) or guinea-worm.

5. The Leptus aniumnalis (Ernteniilbe) or harvest-bug.
In the second class we enumerate,

1 . The Pediculus (Läuse) or louse, including

(i.) The Pediculus eapilis (Kopfläuse), the common louse.

(2.) The Pedicnlns pul/is, sen Plithirins ingninalis, the crab-
louse (Körper- oder Tilzläuse).

(3.) T\\QPediculusvestimeniornm, ^evihimani corporis (Kleider-
läuse) the body-louse.

2. The Pulex irritans (Elohe) or flea.

3. The Cimex lectnlarius (Wanze) or bug.

4. The Culex pipiens (Mücke, Gelse) or gnat.

These parasites may give rise to cutaneous aflfections in two
different ways. By nestling in the skin they irritate it, and dispose
it to take on morbid action, to become hypersemic, and to present
exudations, hremorrhages, degenerations of the epidermis, &c. And
they also excite the sensibility of the cutaneous nerves, and thus
produce itching or pain, which sensations are themselves*[additional
causes of disease.

Besides these general and local agents, of which the effects are

38 TREATMENT.

known to be injurious, there are doubtless many others which have
as yet escaped our observation, for we see many cutaneous affections
arise without being able to point out their source. But we prefer to
confess our ignorance in this matter, rather than to get out of the
difficulty by referring these diseases to chills, errors of diet, mental
disorders, nervous influences, or to the epidemic or endemic con-
stitution, &c. ; wliich expressions are in fact quite vague and desti-
tute of real meaning.

III. — Treahient.

Although in the course of the last few years great attention has,
on all sides, been devoted to this department of medicine, we have
unhappily made as yet but little progress towards the wished-for
end, the cure of all cutaneous diseases. The cause of this lies,
no doubt, partly in the fact that it has been only quite recently and
during a time, very short for making exact investigations, that thera-
peutical experiments have been carried on in a rational spirit, and
without bias. For before one can speak of the action of a remedy
in the treatment of any skin-affection two things must be ascertained :
the course taken by the disease when left to itself, and the effects
Avhich are produced by the remedy wlien applied to the healthy
skin. Our want of success depends also, in part, on our defective
knowledge of the dermatoses, and on the small extent to which the
l)athological chemistry of cutaneous diseases has been cultivated. It
seems to us that a very promising field for investigation is afforded
by dermatology to those who are interested in this new branch of
science. Unfavorable circumstances have, hoM'cver, as yet pre-
vented us from exploring it ourselves ; and this task must, there-
fore, be postponed to a future opportunity or left to other observers.

In the imperfection, or rather in the complete absence of any
rational basis for our therapeutical procedures in the treatment of
skin affections, no expedient remains but pure empiricism. Por
the slight success which we have hitherto obtained we are indebted
entirely to the strictly practical course which we have pursued in
this respect. We have tried methods of the most varied description,
Avhether they were recommended by medical men or by unprofessional
persons, and we have found some belonging to the. former category
less effectual than they were represented to be, while popular reme-
dies, on the other hand, have often done us good service.

TREATMENT. 39

Before passing on to enumerate the different remedial agents^ we
shall be permitted to allude to a few deeply-rooted prejudices
which interfere even now, to some extent, and interfered still more
formerly, with the employment in practice of certain methods of
treatment.

The first of these prejudices which we must combat is the dread
with which local applications were regarded.

Some years since we drew attention to the fact that it is quite a
mistake to suppose that the action of remedies applied to the
diseased or healthy skin is necessarily merely topical and not
general.^ Por we need but call to mind the contagia of small-
pox, syphilis, hydrophobia, and the poisons of serpents, and of the
dissecting-room, which are generally introduced through the skin, to
prove that it is an organ which absorbs very readily many forms of
virus. And that it is equally adapted to absorb medicinal agents
also, and to admit them into the circulation, even while the epidermis
is intact, can be easily shown during the external use of tar, of iodine,
or of the mercurial preparations.

Now, what can be demonstrated in the case of certain remedies
by chemical reactions ought surely not to be denied ä priori in regard
to others; and therefore we maintain the exact contrary of the
principle we have alluded to, and assert that, with the exception of
caustics {A.etz mittel), all remedies which are brought into prolonged
contact with the skin are absorbed by it, and taken uj) into the
fluids of the body.

Hence we have no fear, in applying topical remedies, of driving in
cutaneous diseases, or of producing any other ill effects, for which
the practitioners of the old school had various expressions. Our
apprehension is rather of a too violent action upon the organism in
general, especially in the case of those drugs which are liable to
produce derangements of the vegetative processes. Nor have we
any dread of curing skin-affections too quickly. On tlie contrary,
it is the object of our warmest endeavours to find means of termi-
nating these diseases as speedily as possible. Were we only in the
possession of remedies which produced cures thus rapidly, we should
have no anxiety with regard to the appearance from this cause (Nach
schnell unterdrückten Flechten) of metastases, or of any other con-
secutive diseases.

• ' Zeitschrift der k. k. Gesellschaft der Aerzte,' iii Jahrg., i Bd., 1845,
P- 349-

40 TREATMENT.

There is another point also^ in which we are opposed to our prede-
cessors and to many of our contemporaries^ and that is with reference
to the necessity for using in the cure of chronic skin-affections
remedies whicli are supposed to be purifiers of the blood [Hamaio-
cathartica, Blutreinigende). We have never seen the effects which
are ascribed to them by some authors, produced either by the long-
continued administration of laxatives and drastics, nor by decoc-
tions of woods (Holz-tränke), nor by vegetable juices. J^gain, the
internal use of antimonials, baryta, graphite, anthracocali,' or sulphur;
or again of cantharides, mezereum, viola tricolor, dulcamara, Roob
Laffecteur,2 or sirop de Larrey/ has been invariably unattended with
the hoped-for success, and therefore we cannot recommend to any one
the employment of these agents. On the other hand, arsenic has
proved in our hands a useful internal remedy, though we cannot
praise it to the same extent as do Hunt and Romberg; and we have
also seen good effects produced by the preparations of mercury, of
iodine, and of iron, by the oleum Morrhuse, by the bitters, and the
vegetable and mineral acids ; and, lastly, by all those remedies wliich
are indicated in particular cases by the presence of dyscrasise, and
which would be prescribed equally, although the general affection
Avere running its course unattended by any local disease of the skin.

Externally we make use of simple baths, warm or cold as required,
and of douche baths, and vapour baths ; or we add to these baths
sulphur, potash, soap, common salt, or corrosive sublimate. Their
temperature should be from 66°— 100° F. (15°— 30° E.) ; and
their duration may vary from several days to a few minutes. Again
we often employ emollient frictions with success, rubbing the whole
skin or certain parts of it with oily or fatty substances (such as
the ol. Amygdalse, ol. Lini, ol. OHvse, or ol. Jecoris aselli, or lard,
suet, glycerine, or spermaceti). In other cases we add to these fatty
matters various active substances, such as the preparations of mer-
cury, zinc, lead, copper, iodine, arsenic, sulphur, &c., which remedies,
so far as their solubihty permits, may also be used in watery or
alcoholic solutions. Our sheet anchor, which we invariably employ

* A full account of the nature and therapeutical value of this remedy is given
by Prof. Hebra, when speakiug of the treatment of psoriasis. — [Ed.]

2 "Rob de Laffecteur," is a secret remedy, of which the exact composition is
unknown, but of which sarsaparilla is the principal ingredient. (V. Jourdan,
' Pharraacopee Universelle,' torn, ii, p. 419.)— [Ed.]

3 This is another medicine of the same kind as the Roob Laffecteur.— [Ed.]

TREATMENT. 41

when we wish to effect either the rapid separation of the horny hijer
of the epidermis, or the removal of exudations infiltrating the cutis,
or poured out beneath the cuticle, is always the soft or potash-soap.
This we apply either alone, as in prurigo, eczema, psoriasis,
ichthyosis, pityriasis, herpes tonsurans, favus, lupus. Sec. ; or we
blend with it other medicinal agents, such as for example, sulphur
in cases of scabies, tar in cases of eczema, &c.

Moreover an important part of our therapeutical resources consists
in the empyreumatic oils, which result from the dry distillation of
certain kinds of wood. Thus we make use of the tar which comes
from the beecli (Oleum empyreumat. fagi) , of the Oleum cadinum,
which is derived from the Jumperus oxi/cedrus, and of the Oleum
nisei, which is obtained by distillation from the w^ood of the bircli
(Betula alba), and which possesses the smell of Russia leather.
The action of these is nearly identical; they differ only in their
consistence, and in their smell.

For the removal from the skin of exudations, new growths,
tumours and the like, caustics are employed. Passing over the
actual cautery, of which, as of the knife, the application belongs to
the domain of surgery, we will here concern ourselves only with the
corrosives and escharotics (Aetzmittel), of which we shall refer
particularly to those wliose action we have ourselves thoroughly
tested.

The concentrated mineral acids, namely the strong sulphuric,
nitric and hydrochloric acids, can be applied in comparatively few
cases. Not only is their action inconstant and therefore unreliable ;
but better effects are produced by other caustics. Moreover the
disfiguring scars which follow the use of these acids often frustrate
the purpose for which they were employed. The same may be said
of butter of antimony, of chloride of zinc, and of other similar pre-
parations. There are but few cases in ^yhich we use these substances,
applying for example sulphuric acid in the removal of horny
growths, and hydrochloric or nitric acid to destroy old exudations
which have become organized. For experience has made us
acquainted with better caustics, of which the effects can be more
easily regulated, and which are followed merely by thin and smooth
cicatrices. Among these we place in the foremost rank the nitrate
of silver, which we use either as a solid, or in a concentrated solution
(Argent, nitrat., — A qiice destillatcB, paries aqiialesj. To this sub-
stance we attach a great value, because every kind of new growth

42 TREATMENT.

can be destroyed by it, without causing any further injury to the
patient, and because any one, however unpractised, can apply it,
without having any special experience in its use.

Next to this substance in importance is the caustic potass of the
surgeons ; this may be employed either in the form of sticks, or dis-
solved in two parts of water; but it demands more care in its
application than the nitrate of silver ; and it also causes a more
extensive loss of substance, the limits of which cannot be so
accurately predetermined. Moreover its use is often followed by
thick and raised (wulstig) cicatrices.

Similar effects are also produced by the Vienna paste (Wiener
Aetz-Pasta), consisting of equal parts of caustic potash and quick-
lime, made into a paste with alcohol at the time of its application,
and left for ten or fifteen minutes in contact with the portion of
skin which is to be destroyed. By the chloride of zinc paste of
Canquoin (take of chloride of zinc one part, of flour four parts, of
water q. s.), the same result is attained only after the lapse of four
hours. And a longer time still (twenty-four hours or more) is
required for the action of the paste recommended by Landolfi
(consisting of chloride of bromine two drachms, of chloride of anti-
mony, and chloride of zinc, of each a drachm and a half, besides
chloride of gold ad Ubituni) of which the eft'ects are however more
severe. All these pastes char the organic tissues with which they
are brought in contact ; and they differ only in respect of the inten-
sity of their action.

We may also attain similar results, though only after repeated
applications, by using a ^powder containing five grains of white
arsenic, and fifteen grains of artificial cinnabar, mixed with two
drachms of sugar, or with the same quantity of the unguentum
rosatum, as may be most convenient.

Again, the solution and paste of Plenck, consisting of corrosive
sublimate, camphor, carbonate of lead, alum, spirits of wine, and
vinegar in equal proportions, has been employed with success in the
treatment of various growths, especially those of syphilitic origin.

Sulphate of copper, alum, pulvis sabinse frondum, corrosive

' This formula is founded upon the " Cosme'sche Pulver " of the Austrian
Pharmacopoeia, of which two ingredients are liowever omitted, namely, the
sanguis Braconis, and the ciiieres solearum ustarum (the ashes formed by the
incineration of the soles of boots and shoes).

CLASSIFICATION. 43

sublimate, calomel, &c., are also well-known irritants, which either
alone or in conjunction with other substances, may be used with
advantage for the purpose of destroying, slowly, growths of various
kinds.

Lastly, besides these active remedies, which are used externally
or internally in different skin-aflPections, others which are indifferent
and inert are also frequently prescribed, in those diseases \^hose
course we cannot modify, and in which therefore the expectant
method is attended with the best results. Thus, whether this or
that remedy be used, is a matter of indifference, in the contagious
exanthemata, as well as in all inflammatory affections of the skin
which run an acute course, such as erythema, roseola, urticaria,
erysipelas, herpes, miliaria, pemphigus acutus, Szc. That mode of
treatment which disturbs the patient least is, in these diseases,
always the best.

I Y. — Classification.

Our predecessors and contemporaries have endeavoured, according
to very different principles of arrangement, or even without any
such principles, to distribute cutaneous affections into classes, orders,
and species. These attempts have been crowned with more or less
success, and have obtained for a longer or shorter time, a partial or
even a general acceptance among the profession. They have how-
ever possessed the defect of isolating the diseases of the skin too
completely from those of the rest of the body ; and therefore they
have by no means fulfilled the requirements of a perfect derma-
tological system.

In passing in review the chief works on the dermatoses which
have appeared from the most remote ages to the present time, we
meet with so many systems of classification, that to describe them
all would be judicious or even possible, only if we were writing a
historical account of these diseases. But in order not to pass over
what has been hitherto effected in this branch of medical science,
and to make apparent our reasons for not giving the palm to any
one of these systems, we may mention cursorily some of the more
important of them,

Eor this purjiose we may divide these schemes of classification
into eight classes, founded on the nature of the principle which

44 CLASSIFICATION.

forms their basis_, or on the other hand on the fact that their author
held himself unfettered by any logical rules.

(i) The oldest forms of classification^ those namely of Galen
and Mercurialis^ were based upon the seat of the affection, that
is to say, upon its anatomical distribution; and by these writers,
diseases of the skin were divided simply into those which attack the
hairy scalp, and those which affect the rest of the surface. It
surely needs no further description to show how defective and inju-
dicious is so arbitrary a distinction.

(2) Those systems on the other hand are very tempting, whicli
distribute skin-diseases into the local or idiopathic, and the con-
stitutional, general, or symptomatic. Lorry was the first to intro-
duce this principle of classification ; but the same idea, though often
under different names, has been elaborately worked out and improved
by Dendy, Schönlein, Fuchs, Isensee, and others. But unfortu-
nately, not only may the same cutaneous affection be produced by
the most different causes, but the most varied diseases of the skin
may also be caused by one and the same morbid agent. And it is
not possible in every instance to draw from the form and appearance
of a dermatosis, any certain inference as to its origin from a local or
general cause.

(3) Next there are the anatomico-physiological systems, including
those of Grimaud, Baker, Turner, and Craigie, in the last century,
as well as the more modern classifications of ]loscnbaum, Erasmus
"Wilson and others. These start from the opinion that it is possible
to ascribe distinct names and characters to the affections of the
different tissues which make up the skin; that is to say of the
epidermis, of the corpus reticulare (Malpighii), of the papilla?, of the
corium, and of the follicles, the vessels, the nerves, &c. But these
writers forget that the integument is an organ, of which the com-
ponent tissues are very rarely separately affected by disease, being on
the contrary in most cases all penetrated by the morbid products, so
that it is very often impossible to say whicli strata are more, and whicli
less involved. These systems, therefore, are above all others, wanting
in practical applicability ; and hence they have found few adherents.

(4) Xo classifications, on the other hand, have met with so many
followers, as those which have for their basis the external form of
the disease. Such are those which were first established by
Biolanus and Plenck, and which have since been modified by
Willan, Bateman, Chiarugi, Biett, Cazenave and Schedel, Gibert

CLASSIFICATION. 45

and Eieckcj and others. But although the fundamental idea of
these systems is at first sight very seductive, yet it can sustain no
close criticism, and is far from being verified by practice. They
have in fact been the great cause of the erroneous notion, that for
the recognition of a cutaneous disease, it is sufficient to determine
the primary efflorescence, which existed in that particular case. It
was supposed that it is thus easy to fix upon the genus, to
which the skin- affection belongs; and that there is then no diffi-
culty in making out the name of the disease, by seeking for the
special marks which characterise each species of the dermatoses.
As though for the determination of a disease, a single character is
sufficient, although it be torn from its connexion with the other
symptoms with which it is associated, and although all the other
appearances which present themselves in the course of the case are
left unobserved, and the only point investigated is whether, at its com-
mencement, the affection presented a macule, a papule^ a vesicle, a
bulla, a pustule, or some other of the primary forms of efflorescence !
Such a method of diagnosis reminds one only of the empirical
uroscopy of our fore-fathers and certain of our contemporaries.
Moreover these classifications had the further disadvantage, that
they isolated diseases of the skin from the doctrines of nosology
in general, that they made the morbid processes which occur in the
skin, appear quite diff'erent from those which affect other parts of
the body, and that they thus called into existence those erroneous
conceptions of cutaneous diseases, which, even at the present time,
we meet with in every direction.

No doubt the founders of these dermatological systems had
floating before their eyes the Linnean classification of plants. For
they sought for the characters of their genera and species in certain
among the appearances of the dermatoses {Efflorescentice cutanea:,
Hautbliithen) just as Linnaeus employed for the same purpose the
special parts of the flower (Blumen, Blüthen). But this attempt
resulted in failure.

(5) Equally unsuccessful were those who, with Ahbert at their
head, and following De Candolle and Jussieu in botany, tried to
introduce natural systems, as they were called, in dermatology.
Their fauure arose simply from the fact that a skin-disease does not
form an individual, but merely consists of changes occurring in in-
dividual persons.

In forming a closer estimate of the two clauaificatious of Alibert,

46 CLASSIFICATION.

it cannot but be seen that some among the groups of dermatoses
may fairly lay claim to the title of natural families. Such are the
contagious exanthemata (morbilli^ scarlatina^ variola) ^ the syphiiides^
and the eczematous eruptions. But some only, not all afPectioiis of
the skin admit of being thus arranged ; the basis of classification is
not the same in the different groups ; and this system, even if it were
practicable, would result in the isolation of dermatology. And for
these reasons this method of classifying cutaneous diseases is devoid
of all practical value.

(6) The course and duration of affections of the skin, their being
acute or chronic, and their being attended or unattended with fever,
gave to Derien and Frank a basis of arrangement, according to
which they divided dermatoses into the acute and the chronic, into
the exanthemata and the impetigines. Now there are certain
cutaneous diseases, such as the contagious exanthemata, which are
always acute; and there are others (prurigo, ichythyosis, elephan-
tiasis, &c.), of which the course is invariably chronic. But there
are also many affections of the integument, which sometimes termi-
nate quickly, and yet are unaccompanied by fever; and there arc
others, of longer duration, in which feverish symptoms are always
present. Nay even the same disease may run now an acute, now a
chronic, course, as we see in the case of urticaria, eczema, and
impetigo. Hence it is evident that, in this respect, cutaneous
diseases form no exception to what we know of the affections of
other parts of the human organism. In both cases the same
complaint, without alteration of its essential nature, may be either
acute or chronic, either attended or unattended with fever.

(7) Other authors in constructing their schemes of classification,
seem to have been struck with the difficulty, not to say impossi-
bility, of carrying out logically a division of the dermatoses on
either a natural or an artificial basis. Hence they have contented
themselves with arranging in groups those affections of the skin
which were most closely allied to one another, with imposing
on them the names of classes or orders, and with describing
in succession, under these different heads, the correspondmg
diseases. It was in this way that the systems of Rayer, Plumbe,
Devergie (his later method), Chausit (Cazenave), and others were
drawn up.

(8) As curiosities we may mention, lastly, certain classifications
which can be regarded only as examples of abortive attempts. Such

CLASSIFICATION. 47

are the "Fluxions" of Baume (Fluxions — (a) par cause externe, re-
ßechie, deplacee, excentrique, — (b)^j«r diathese, idiopathiqiie, coraplexey
^c.J; Struve's division of the dermatoses into cryptogamese and
phanerogamese ; Devergie's earlier system, by which diseases of
the skin were distributed into maladies secretantes, et non
secrelantes ; and Upman's classification^ according to the mutual
presence as well as the mere nature of the elementary forms of
eruption (as for example, into vesicles with, and vesicles without
papules, &c.).

The inadequacy of the systems, which had up to that time been
drawn up, and the want of uniformity between the method of clas-
sifying diseases of the skin, and that applied to affections of other
parts of the body, induced me, as far back as the year 1844, to
propose a division of the dermatoses on a pathologico-anatomical
basis, in which I adhered for the most part to the doctrines taught
by Kokitansky. I have as yet found no reason to repent of the
scheme which I then^ published, or to make any essential alterations
in it. But I have had occasion to observe that it has been made
use of, and modified by several authors in the erection of their
systems. This is, indeed, easily explained by the consideration that
they all have derived their knowledge from the same source as
myself, namely, from Rokitansky.

I feel all the more satisfaction in being able to repeat, with but
little alteration, the views which I advanced twelve years ago, be-
cause my experience has been greatly enlarged since that time, by
the observation of more than 80,000 cases of cutaneous disease, and
because my opinions with regard to certain of the dermatoses have in
many respects undergone a change. Not that I wish to represent my
system as free from defects, and to maintain that no better one can
possibly be at any future time proposed. Its faults and deficiencies
are only too well known to me. But, in my belief, it is superior to
others in this, that though artificial, it is not too refined (kiiusthches
doch kein gekünsteltes), and that though it is not a natural clas-
sification, it is yet in accordance with nature (obgleich kein
natürliches doch ein naturgemässes) . For it places together those
diseases of the skin which resemble one another in their essential
nature ; and it makes no arbitrary separations between allied affec-
tions.

' ' Zeitsclirift der k. k. GesellscLaft der Aerzte,' ii Jahrg., i B. 1845, PP- 35»
143, 211.

48 CLASSIFICATION.

Ill passing now to the description of our system, the first question
to be answered is, why have Ave divided the diseases of the skin into
twelve classes ? We freely confess that we might have contented
ourselves with ten or eleven, for the separation of the eighth from the
ninth class may be termed arbitrary, and even incorrect, from the
histological point of view. Again, in accordance with precedent, it
was not necessary to have introduced the ulcers into dermatology,
or at least not as a distinct class. But the proverb says, ^^ Q?ii bene
distingult bene docet j " and from the practical point of view which
I have always kept before me, it appeared to me to be judicious
to adopt this classification; according to which all the diseases of
the skin may be reduced to twelve divisions, classes, or families, as
follows —

^ Class I. — Ilj/peratnice cutanea — Hypera^mic affections of the
skin.
II. — Anamia cutanea — Anemic affections of the skin.
III. — AnomaVue secretionis glandularum cutanearum — Morbid

conditions of the secretions of tlie cutaneous glands.
IV. — Kvudatlo^ies — Exudations and exudative affections.
V . — llamorrhaglce cutanea — Haemorrhages.
VI. — Kypertroi^m — Hypertrophies.
VII. — Atrophia — Atrophies.
VIII. — Neoplamnata [Homaoplasia) — Innocent growths.
IX. — Psetuloptlasmata {HeteroplasUc) — Malignant growths.
X. — Ulcerationes — Ulcers.
XI. — Neuroses — Neuroses.
XII. — Parasita — Parasites.

The characters belonging to these classes will be given hereafter,
in describing the cutaneous affections which are included under each
of them.

1 For tlie denomination of the first eleven classes, or families, I have employed
the name of a pathological proces'', that is to say, of a thing which, being only
a conception of the mind, and invisible, can be recognised only by its effects.
On the other hand, the name of the twelfth class is derived from the cause of
tlie diseases which belong to it, which cause is positive, and has a real
existence. But although I must thus admit the logical <lefect in the principle
of classification which I have adopted, yet I have not been able to remedy it,
without risking the practical usefulness of the system.

CHAPTEE III.

CLASS I.— HYPER^MI^ CUTANEA.

Diseases of the Skin, which arise from the presence of an excess of
Hood in the capillary vessels of the cutis.

By a state of excessive injection of the capillary vessels of the
derma, and by the impeded circulation to which this condition gives
rise, many morbid appearances are produced. These may often
enough be observed in the living patient alone and unattended with
any demonstrable exudation or heemorrhage, so that no facts, either
anatomical or physiological, are opposed to the association of these
diseases into a single class, and the description of them apart from
other pathological changes.

The following characters belong to the cutaneous hypergemiee in
general.

a. Redness of the shin. — This presents every shade, from a bright
red or rose colour to a dark, bluish-red. But it always yields to the
application of pressure ; and when this is removed, the normal colour
of the skin is seen, though only for an instant, after which the red
colour quickly re-appears.

b. Swelling/. — This is often imperceptible, and is seldom con-
siderable.

c. The temperature of the shin is not demonstrably altered in con-
ditions of slight hypersemia, but in severe instances of this affec-
tion it presents deviations from the norm, appreciable both by the
touch, and also by the thermometer.

d. Subjective sensations, — The patient either feels no abnormal
sensation, or merely a slight itching or burning.

e. The seat of the affection is either in the papillse alone, which are
extremely vascular, or also in the deeper capillary net-work of the
cntis, or lastly, in the capillary vessels which supply the hair sacs
and glandular structures.

50 ACTIVE HYPERiEMIiE.

f. As regards their form, these rashes consist for the most part
only of maculEBj which are either chcumscribed and of varied pattern
(figurirt), or diffused ; but wheals are also sometimes present.

g. Their course is generally acute, and often of a definite type ; in
some cases it is chronic, from the occurrence of repeated relapses.

h. Their duration is from a few minutes to several days.

i. Secondary or consecutive a]ipearances are, in these affections,
generally wanting, but in some cases pigmentation of the epidermis,
and in others slight desquamation (defurfuration) is observed.

The immediate cause of an hypersemia must be either an increased
flow of blood to the part or an obstruction to the circulation, from
stasis of the blood. Since each of these conditions may occur in
the skin, the generally adopted division of hypersemia? into the
simple or active, and the passive, mechanical or hypostatic, is neces-
sary in dermatology.

A. — Active Hyper/emi^.

Symptoms, — A colour varying in tint from a pale rose to a bright
blood- red, disappearing beneath the pressure of the linger ; no per-
ceptible swelling; elevation of temperature; sensations of slight
itching or burning : such are the phenomena which indicate these
forms of hypersemia.

Subdivisions. — ^We distinguish an idiopathic from a symptomatic
hypersemia. In the former case the affection is purely local, a skin
disease in the strictest sense (dermatonose, Ftic/is). In the latter
case it is produced by disease of other parts of the body, attacking
also the skin (dermapostase, FucJis).

A. IDIOPATHIC ACTIVE HYPER^MIffi.

Under this head we shall describe all those rashes which arise
from injuries affecting directly the cutaneous surface, and in which
nothing occurs beyond the accumulation of blood in the part, or in
which at least the hypersemia is the first and most striking morbid
change.

Since the name erythema has always been given to all affections
in which the skin assumes a diffuse red colour, we, will make use of
the same expression. We shall take leave, however, to add to it
the epithet " conr/estivum," in order to indicate more precisely the

ACTIVE IDIOPATHIC HYPER^MI^. 51

form which is to be here described, for we shall hereafter, among
the exudative processes, have to speak of an erythema exudativum.

ERYTHEMA CONGESTIVUM IDIOPATHICUM.

The erythema congesthmm is characterised by the symptoms which
belong to the active hypersemise of the skin, and by the absence of
all phenomena pointing to disease of any other part of the organism.
The extent and pattern (Zeichnung) of this rash vary according to
the kind and degree of the injurious influence which produced it,
and to the susceptibility of the patient.

It would, of course, lead us too far from our immediate purpose
if we were to attempt to enumerate all the causes which may give
rise to an active idiopathic hypersemia in the form of erythema con-
gestivum. We must therefore content ourselves with mentioning
tliose forms of the affection only which are either most frequently
the subject of observation, or of which a knowledge is necessary,
for the discrimination of other more severe skin diseases, in which
they are merely temporary phenomena (Uebergangserscheinungeu).

(i.) Erythema Traumaticum.

The pressure which the skin undergoes from tightly fitting clothes
or bandages, from the various postures of the body, and from rubbing
or scratching, causes a reddening of the parts affected, of which the
pattern varies with the form of the body which produced it. This
redness, however, quickly disappears when the pressure is removed,
and leaves behind no trace of its presence, unless the operation of
the offending agent was either unusually intense or of long duration.
Thus, we see red spots of different forms, which are produced in
men] by tightly fastened belts, in women by stays, tight bands,
and closely fitting garments, and in both sexes the same thing is
observed at those points which bear the pressure of trusses, or of
their pads or straps. Similar red patches are fomid over the sacrum
or the ischial tuberosities, after lying down or sitting upright.
Again, in those individuals who scratch themselves with their finger-
nails, or whose skin is rubbed in other ways, we see reddenings of
the skin, which are of greater or less extent, or may take the form of
strias : and so long as these appearances are of short duration only.

52 ACTIVE IDIOPATHIC HYPEU^MIyfi.

and disappear totally Mdien the pressure is removed^ they are the
result merely of hypersemia of the capillary vessels of the papillae.

If, however, the same irritant acts upon the skin repeatedly or
continuously, the hypersemia may at length amount to stasis and
exudation, or, in other instances, may lead to haemorrhage. In both
cases, other cutaneous affections are called forth, which Avill be
described in the proper place.

The knowledge of these appearances is necessary in itself, so
that in practice they may be rightly understood, and that more
importance may not be attached to them, than they deserve.
Another circumstance also must always be remembered, namely, that
portions of the skin which arc the seat of this kind of hypersemia,
even to a trifling extent, are often observed to be specially affected
by the exudative cutaneous diseases. Thus when variola breaks out
in Avomen, the pustules are far more numerous round the middle
of the body, and above the calves, where tightly-fastened belts and
garters are worn, than on parts of the skin which have not been
exposed to pressure. So again, if persons whose occupation keeps
them sitting continuously on hard stools or benches, become affected
with scabies, there are always found on the buttocks over the
ischial tuberosities, not only numerous cuniculi, but also tubercles,
vesicles and pustules. Other instances of the same kind miglit
be cited.

(2.) Erj/tJiema Caloncum.

Bashes, which result from the action of heat or cold upon the
skin, are to be regarded as simple hypersemise, so long as, beyond
the change of colour, no other deviations from the normal state
make their appearance. But when, in addition, the existence of
inflammatory products in the part is shown by the presence of
swelling, or by the formation of vesicles or bullte, the affection is
then one of a higher degree and belongs to the domain of the
exudative processes.

We may quote as an example of hypersemic eri/ihema caloncum
the reddening of the surface which is produced by warm or cold air,
and by hot or cold baths. When the operation of these agents is
withdrawn, the colour disappears, leaving behind it no mark of its
presence, in the form of either desquamation or pigmentation.

ACTIVE SYMPTOMATIC HYPERiEMJiE, 53

(3.) Erythema ah AcribuSy seu Venenatum.

As is well known, wc possess several substaucesj M'hicli by tlieir
chemical properties have au irritant action upon the skiu^ and
produce, as their first etfect, an engorgement of the capillaries of the
cutis, in other words an hj'perfcmic erythema. Under the continued
operation of these agents, however, inflammatory products are poured
out, both into the cutis, thus giving rise to an exudative erythema, and
also beneath the epidermis, so as to form papules, vesicles, or bullre.

\Ye are familiar with certain of these rashes produced by
various mineral, vegetable, and animal matters ; for example, by the
Hepar snJph'.ris, by the Semina shuqns, and by the hah's of the
caterpillar of the Gastro2)acJia processionea. The form and extent of
these eruptions depend on the nature of the substance which caused
them and the duration of its action, and they are generally confined
to the part of the skin with which it came into direct contact.
But examples are by no means wanting in which an irritant acting
only upon a small circumscribed spot, has given rise to a Avidely
diff'used, and even universal redness of the surface.

B. SYMPTOMATIC ACTIVE HYPER-EMI.E.

In the course of general diseases of various kinds, both in
those which are attended with fever and those in which there
is none, we meet with rashes, of which these affections are
evidently the cause. These appearances may either precede the
principal malady, as in the case of the so-called roseola variolosa ;
or they may accompany it, as does the strophilas volaticus ; or,
lastly, they may show themselves at a time when the primary disease
is undergoing involution, as is the case with the roseola vaccina, and
the roseola cholerica. Even in healthy persons similar rashes are
seen as a result of nervous influence or of mental disorders. Who
is not acquainted with the flush, which generally affects only the
cheeks, but which frequently covers all the face and neck, and even,
in exceptional cases, the whole surface of the body, and which,
though termed the blush of shame (Schamröthe) , is caused quite as
often by anger, vexation, or confusion ?

Now although some general afi"ections are, more frequently
than others, accompanied by such erythematous rashes on the
skin, yet the connexion between the disease and the eruption

54 ACTIVE SYMPTOMATIC ITYPERiEMI.E.

is not so close that tlie one cannot l)e found without the
other. Thus we find typhus occurring M-ithout^ as well as with,
roseola. The efflorescence then is not an indispensable part of
the phenomena presented by the general disease, but may be present
or absent without affecting the essential characters of the latter.
Indeed the course of the complaint is not even to an important
extent modified by the appearance of these rashes, and it is only in
certain cases that their presence is of any consequence even in rela-
tion to prognosis.

An acquaintance with these forms of erythemata has however a
negative value. It saves one from the common mistake of
diagnosing every febrile complaint, attended with a reddening of
the skin, as one of the contagious exanthemata (scarlatina, morbilli) .
Such conclusions, when made too hastily, often lead to disagreeable
consequences.

In reference to these symptomatic erythemata, we might content
ourselves with what we have already said, and group them together
under the name of erythema fugax, which is applied to them in
medical works. But as some general diseases are more frequently
than others attended with such rashes, and as in dermatological
works many terms are mentioned, which would naturally be placed
in this part of our system, it will be well for us to enumerate them
in this place.

Under the name roseola [rosalia, I'uheola, rose-rash, Röthein,
Kitteln, Wiebeln, Feuermasern, der rothe Hund), is understood
by Willani a " rose-coloured efflorescence, variously figured, without
Avheals or papules, and not contagious."

Such is "NYiUan's definition of roseola, which he divides into a
roseola astiva, aiitumnalis, annnlata, infantilis, variolosa, vaccina,
and miliaris. He mentions in conclusion another form also as
occurring in typhus (contagious nervous fever). Other authors,
such as Rayer,^ Alibert, and Fuchs,^ have thought fit to enumerate,
besides these, other varieties of this affection, and describe, besides
those already given, a roseola febrilis, rJieicmatica, cholerica, idio-
pathica et symptomatica, saltans, &c. In addition to these nume-

1 'On Cutaneous Diseases/ by Robert Willau, M.D., 1808, vol. i, p. 433;

2 'A Theoretical and Practical Treatise on Diseases of the Skin.' By
P. Rayer, M.D., 2nd Edition, translated by D. Willis, 1835, p. 192.

3 'Die krankhaften Veränderungen der Haut, &c.' Von C. H. Fuchs,
GötUngen, 1840, pp. 177, 927, 1024, and 1065.

ACTIVE SYMPTOMATIC HYPER^MIJE. 55

rous species of roseola, there are also several other names which have
been applied by these and other dermatologists to symptomatic
hyperamise of the skni. Thus the strophulus volaticiis and inter-
tinctus, the Feu des Dents of W'illan, the Nirlus of "Wilham Bat,
and of Alibert, the Feu rouge of the French writers, and the
^^Eed Gown" and "Wüdfire Eash" of EngHsh physicians
are clearly nothing more than transient forms of erythema, which
may accompany now this, and now that complaint.

I think that I need devote a special description only to the
following varieties of erythema and roseola.

(i.) Eri/tliema Infantile, seu Roseola Infantilis.

In the infantile organism, as is well known, all the manifestations
of disease display a severity, which is not observed .in the case of
adults. In fact quite trifling disorders of the health are in children
often attended with severe (stürmisch) symptoms. Thus as a result
of the so-called catarrhal, rheumatic, or gastric fever, of the process
of dentition, of the presence of worms and so forth, we meet in
these little patients with rashes, which are sometimes diffused over
large tracts of the skin and thus resemble a scarlatina, whereas in
other cases they present distinct maculoe, and then simulate the
aspect of measles.

Those, therefore, who hold the opinion that, for the diagnosis
of the contagious exanthemata, it is sufficient to attend to the
appearances presented by the skin, will often be led into the
error of regarding these transient rashes as an evidence of measles
or scarlatina. But observation of the further course of the case
will soon teach them the contrary ; for in the exanthematous
fevers the eruption has a definite and longer duration, whereas, if
it be an erythema or a roseola, it vanishes as rapidly as it appeared,
lasting a few hours only, or at most a day. Moreover, these forms
of rash do not, either when they break out, or while they are dis-
appearing, present that regular mode of development and of retro-
gression which we are accustomed to see in rubeola and in scarlet
fever. Again, those symptoms are absent which, being constantly
present in the exanthemata, form part of their essential characters.
I refer to the severe catarrhal disease of the air-passages in measles,
and the more or less intense inflammatory affection of the pharynx
in scarlatina. A further aid in the diagnosis of the erythema infantile

56 ACTIVE SYJirTOMATIC HYPEUiEMIiE.

or roseola infmitilis is afforded by the circumstance that when this
rash disappears it leaves behind it neither deposition of pigment nor
desquamation of the epidermis.

As for the subjective symptoms of these affections^ it is to be
noted that the patients frequently spealc of a feeling of increased
heat, and of slight itching or pricking. These sensations are, how-
ever, of but short duration, coming to an end as soon as the objective
symptoms disappear.

The roseola infantilis, then, according to the description we have
given, is no independent malady, and can only be regarded
as a symptom accompanying other diseases. It may show itself
either in the course of slight affections, which always terminate in
recovery, or in the more dangerous and fatal general disorders.
Moreover, it cannot be looked on as either a favorable or an un-
favorable sign, in reference to the probable issue of the disease
which causes it. Hence this variety of erythema or roseola possesses
no special importance, so far as prognosis is concerned, nor is there
anything worthy of mention in regard to its treatment. The ex-
pectant method, or the employment of inert substances, is fairly
applicable to this affection.

(2.) Erythema Vanolosim, Roseola Variolosa,

During the preliminary stage of variola, before the appearance of
the eruption, and generally on the second day of the disease, it is
not uncommon either to find the whole surface of the body covered
by a diffused rash [erf/fhema), or to observe scattered spots [roseola)
of a bright red colour, and in size between a lentil and a finger-
nail, which appear first on the face, and afterwards on other
parts of the body. The duration of this efflorescence is very short.
"V^'ithin twelve or twenty-four hours the true variolous eruption
gradually makes its appearance, and the earlier rash fades away as
the characteristic papules become fully developed. The diagnosis
of a roseola variolosa, or of an erythema variolosum, is of course
impossible at the commencement of the affection, and can be made
only at a later period, when the ordinary smallpox efflorescence has
shown itself. The occurrence of this erythema has thus frequently
been the cause of mistakes ; for, relying on the presence of a red
rash, accompanied with febrile disturbance, medical men have believed
that they had to do with measles, in cases in which all the characters

ACTIVE SYMPTOMATIC IIYPERJ3MI/E. 57

of variola have soon afterwards manifested themselves. A similar
explanation may be given of the statement made by certain writers^
that morbillij scarlatina, and variola sometimes occur in combination,
attacking simultaneously the same patient, an opinion which arose
from an erroneous interpretation of this form of erythema or roseola.

I cannot refrain from availing myself of this opportunity to throw
my authority, based on the experience of many thousand cases of
disease, into the same scale with that of those authors who deny
that more than one of the exanthemata can be present at the same
time. I have, of course, seen one of these diseases (such as variola)
appear after the complete termination, that is, at the end of the
stage of desquamation, of another exanthem (as, for example,
morbilli). But, according to certain authors, two exanthemata
(morbilli and variola, scarlatina and variola, or even scarlatina and
morbilli) may exist at the same time and in the same patient. Of
tliis I have never been able to assure myself, and, in my opinion,
no proof of it is to be obtained.

Another peculiar appearance, which precedes the eruption of
variola, must also be mentioned, although the similarity between
its course and that of the affections which w^e have been describing
is the only reason for introducing it in this place.

Quite at the beginning of the preliminary febrile symptoms of
smallpox there is in some cases observed on the abdomen, and on
the inner sides of the thighs, a rash, which is sometimes a mere
hyperaeraia, and disappears beneath the pressure of the finger, but
which is, in other instances, of an hEemorrhagic nature, and then
persists without change.

This rash invariably remains confined to a space bounded
above by an imaginary line drawn transversely across the um-
bilicus, at the sides by the lumbar regions, and below by a line
traced across both thighs, about three fingers' breadths above the
knees. It also extends further outwards in the inguinal region than
lower down towards the knees ; so that, when the thighs are pressed
together, the area occupied by the rash forms a triangle, w-ith its
apex directed downwards. Some two or three days after its appear-
ance the true smallpox eruption begins. This, as in other cases,
gradually spreads over the whole surface, except that it leaves un-
touched the tracts already mentioned on the abdomen and thighs.
Indeed, in proportion as the development of the variolous vesicles
advances, the intensity of the rash observed on these parts diminishes ;

58 ACTIVE SYMPTOMATIC HYPER.EMI^.

SO that, by the time suppuration begins, these regions have either
become quite pale or present merely a deposit of pigment. In eitlier
ease they are free from the shghtest trace of the smallpox efflorescence.

This erythema may show itself at any time, and affects men as
well as women. But it is much more common in some epidemics
of variola than in others, and it is also far more frequently ob-
served in the female than in the male sex.

In relation to prognosis, again, the appearance of this rash upon
the abdomen of a smallpox patient is by no means necessarily to be
regarded as an unfavorable sign.

These cases do, however, more often terminate badly, than in
recovery, and particularly when the affection passes beyond mere
hypersemia into haemorrhage, when, in fact, a jmrpura rather than
an erythema shows itself on the abdomen and on the thighs in the
stadium prodromorum of variola.

(3.) lioseola Vaccina.

It is well known that inoculation, either with variolous matter
(the contents of the pustules of variola vera) or with vaccine lymph
(taken from the eruption found on the udders of the cow, or from
the vesicles of a patient previously vaccinated), gives rise to a
general disease. This often manifests itself merely by the repro-
duction of vesicles similar to those which yielded the matter for
inoculation. Sometimes, however, there are also produced affections
of other parts of the skin, of which the most frequent is the appear-
ance of simple, red, distinct spots. This rash, which is the roseola
vaccina, shows itself between the thhd and the eighteenth day
after inoculation, generally first upon the arms, and the size of the
maculae varies from that of a fourpenny-piece to that of the palm of
the hand. It often persists only during a few hours, and rarely
lasts more than one day, after which it disappears without leaving
behind it either deposit of pigment or desquamation. A few cases
do, indeed, occur in which this rash spreads over the adjacent parts
of the skin, and thus gives rise to a diffused erythema; but these are ex-
ceptions. Beyond shght attacks of pyrexia, which are of short duration,
no disturbance of the health of the patient is generally observed,
and, therefore, any medical treatment appears to be superfluous.

It is a different affair, however, when these affections, consequent
on inoculation, attain a higher degree of intensity, and when the
lymphangioitis, which was the cause of the erythema or the roseola.

ACTIVE SYMPTOMATIC IIYPER^MI/E. 59

passes into äermat'ii'is. We then meet with erysipelas, infiamma-
tiou of the subcutaneous areohar tissue, abscesses^ furuncles, and even
gangrene^ which not unfrequently imperil the life of the patient, and
are always attended by a number of severe symptoms — symptoms
which, though they may be sometimes connected with it, are
generally absent in cases of the simple roseola.

There are also other appearances which sometimes present them-
selves on the skin after vaccination, and which, in their intensity
and importance, hold an intermediate place between the roseola
vaccina and the more severe forms of inflammation of the skin.
These consist in the formation of papules, wheals, vesicles and buUse,
and are described by certain authors^ as liehen, Mrtiearia, eczema,
and jjempJiigus vaccinatoruvi. Such names are not, however, in my
opinion, rightly applied to these affections, for in dermatology, as
in W\Q other branches of medicine, the distinction between a disease
(Krankheit) and a symptom of disease (Krankheitserscheinung)
should always be observed.

As we have already stated, in giving the general characters of the
active hyperaemiae, all the skin affections which are ranged under
this head run an acute course, and are of short duration. Their
cause varies in different cases, and there can therefore be no ques-
tion of any special treatment for the forms of erythema and roseola
which have been described in this place. We must confine our-
selves to remedying the disease which gave rise to the rash,
according to the indications which present themselves in each
particular case. The erythema or roseola, as a shin-disease, calls
for no treatment.

Among the hi/peramic erythemata, and roseola, I have of course
been able to introduce those forms only, which in the majority of
cases arise merel}" from an excessive injection of the cutaneous
capillaries. There are however other varieties which are caused by
exudative processes; such are the roseola typhosa, cholerica, Sfc.,
and the erytJiema papulatnm, nodosum, 8)C. These are placed by
Willan in the same class with the others, but their proper position
is obviously not here, but among the acute exudative processes of
which the skin is the seat.

It is, I think, scarcely necessary for me to justify this division of the
skin-affections, which were grouped together by Willan and by many

1 'Alois Bednar, die Krankheiten der Neugebornen und Säuglinge, &c.,'
Vienna, Gerold, 1853. (iv Theil, s. 127.)

60 PASSIVE IIYPERiEMIJ:.

of his followers, uucler the names Roseola and Eri/thema. In the
classification of the dermatoses, I have started from principles which
are entirely different from those of Willan^ and with these principles
the arrangement of individual diseases must of course be made to
accord. Indeed when I thus distinguish the forms of erythema
and roseola, caused by exudation^ from those which are merely
hyperajmic, I am not, in my own opinion, making a division
between diseases of the same kind; I am rather separating from
one another cutaneous affections, which arise by entirely different
morbid processes, and I am classifying together those of which the
origin is the same.

B. — Passive Hypeh.emi^,.

Siimjptoms. — A bluish-red (li\id) or bluish-black coloration of
the skin, disappearing under pressure; swelhng, which is but slight
unless oedema be also present ; diminished warmth of the surface :
these are the symptoms of the so-called passive hypersemirej which
result from stasis of the blood (Blutstauung).

Subdivisions. — As in the active hypereemise, so also in the
passive, we distinguish the idiopathic forms from those which are
symptomatic.

A. IDIOPATHIC PASSIVE HYPEE^MLE.

We have seen that irritants of various kinds, if their action upon
the skints surface be transient and not severe, lead to the pro-
duction of the active hypersemise, and the same agents may also
give rise to the passive forms of congestion, particularly if their
operation be somewhat prolonged and be exerted on the larger
venous trunks. Thus pressure upon any part of the skin, if it be
not too severe or too long continued, will be followed by the appear-
ance of a bright rose-tint of the surface (that is to say of an active
hypersemic state) ; whereas even a moderate pressure, apphed
directly over one of the larger superficial vems, will cause a bluish-
red tint of the distal parts, or will, in other words, produce a passive
hyperaemia.

These local blue colorations of the skin require to be distinguished
from those which arise from internal causes, and are hence for

IDIOPATHIC PASSIVE HYPER^EML^. 61

the most part universal. These last bear^ as is well known, the
name of cijanosis (Blausucht) ; and we will therefore give to the
former variety the names livor cutis, livedo (Blauung), and will
divide them into a livedo mcchanica, and a livedo calorica.

(i.) Livedo Meclianica, — Blueness of the skin, 'produced hy
mechanical causes.

This form of afPectiou is characterised by a coloration of the skin,
which varies from a leaden-grey to a reddish-blue, or bluish-black
tint. It is generally confined to circumscribed parts of the surface,
is observed chiefly on the extremities, and is associated with more
or less oedema. When the cause which gave rise to it is removed,
it gradually becomes less perceptible, and finally disappears without
producing any further effects. Diminished mobihty of the parts in
which the circulation is thus retarded, as well as impairment of sen-
sation, or feelings of formication and itching are symptoms which
sometimes accompany this afi'ectiou.

We see these affections produced in every-day life, chiefly by
the action of tightly fitting articles of clothing, bandages or garters,
which surround an extremity, and compress it, so that the circu-
lation through the superficial veins is retarded. The blood is thus
gradually made to accumulate in the smaller veins; its flow through
the capillaries, and their functions are consequently interfered with,
and so the condition, already described, is produced.

As is well-known, before proceeding to perform venesection, it is
usual to compress one of the larger superficial veins, and under
these circumstances, if the bandage be too tight or be left on too
long, we have an opportunity of observing this form of coloration
of the skin.

Pressure may however also be exerted upon the cutaneous veins
by disease seated in the subjacent soft parts, or in the bone, as for
example, by tumours, and in these cases the appearances in the
skin will be the same. Moreover obstruction of the circulation,
and accumulation of the blood in the distal parts of the body, may
also be the result of diseases of the veins themselves, such as defects
in their valves, paralysis, or a varicose condition. We see this
especially in the legs of those persons who are frequently compelled to
stand continuously for a long time. In old people, again, we meet

62 IDIOPATHIC PASSIVE HTPEUiEMI^.

with lividity of the hands and feet^ apart from other disease ; and
it is then the result, as would appear, of deficient innervation.

(3.) Livedo Calorica. — Blueoiess of the skin , 2yroduced hy the
infljience of cold.

Daily experience teaches that the skin of some people is extremely
sensitive to cold. If these persons undress in a room at a tempera-
ture of 63° — 68° F., and still more, if they remain for some time ex-
posed to such a temperature in a state of partial or complete nudity,
their veins become injected to so great a degree, that the plexuses
which these form, can be seen exactly as on the skin of a corpse
(sogenannte Todtenflecke) . Under such circumstances, the surface
presents bluish-red or dark-blue lines, of about two centimetres in
width, communicating together, and forming circles or various ser-
pentine figures. These appearances are observed chiefly on the skin
of the extremities, and to a less extent on that of the trunk. They
yield completely to the pressure of the finger, but quickly return
when it is removed ; and it is only when the patient has dressed and
become warm that they finally disappear. This effect of cold is
seen more often in young subjects than in those who are older, and
occurs especially in the female sex.

Mention must also be made in this place of the bluish-red or
dark -blue coloration of the skin which is observed in some persons
on the hands and on the face, and particularly on the nose, and
cheeks, after exposure for a short time to the influence of the
more severe degrees of cold. The blue colour persists however only
so long as the action of the cold continues, changing immediately to
a natural or a bright-red tint, under the influence of a higher
temperature, and this fact and the absence of sweUing, sufficiently
distinguish these appearances from chilblains {Perniones, Frost-
beulen) .

I cannot refrain from mentioning here a condition which is
observed in some cases on the skin of the extremities, and chiefly on
the hands, as an effect of cold. It consists in the appearance of
distinct spots of a vermilion-red colour, seated upon a more or less
livid base, and in size between a lentil and a fourpenny-piece.
These red spots, combined with the blue colour of the rest of the
skin, give rise to a marbled appearance, and remind one of the
aspect presented by the lungs of an infant, who has breathed only

SYMPTOMATIC PASSIVE HYPERvEMI^. 63

for a short time^ and imperfectly. Can these vermihon-red spots on
the skin possibly owe their origin to a similar process, to a cutaneous
respiration ? We will leave this question to be answered by the
physiologists, and will content ourselves with alluding to the fact.

Remark. — Although the passive hypersemise, which have been
hitherto described, seem in themselves to have but little importance
among the appearances caused in the skin by disease, yet an acquaint-
ance with them is in some cases of no little moment. It enables us, in
fact, to explain correctly many anomalous and exceptional conditions
presented by cutaneous diseases, with the normal appearance of which
we are familiar. We can thus understand how aifections which are
generally attended with a bright red coloration of the skin, may some-
times present a bluish-red hue, without change in their essential
nature. AYe shall also be able to avoid the error (by which the study
of cutaneous diseases has been made so complicated) of seeing in
every different coloration of a familiar dermatosis a specimen of a
new and distinct variety, and of immediately creating for it a new
specific appellation. Thus, for example, "Willan, under the name
lepra nigricans, has figured and described a disease of the lower
extremities, which is evidently nothing more than a common
psoriasis, seated on the legs of a person affected with varices of the
superficial veins, and in which the usual bright-red colour was
changed into a bluish-red or blackish-blue by the passive or me-
chanical hypereemia.

B. SYMPTOMATIC PASSIVE HYPER^MI^.

The blue discolorations of the skin which come under tliis head
are distinguished chiefly by the following pecuharities. They
mostly affect large portions of the surface, and are seldom confined
to any particular region. They have a much darker tint, and are
generally of much longer duration than the idiopathic passive hy-
persemise; indeed, they may persist during the ^hole life of the
patient. They are also connected with affections which cause, either
permanently, or at least for a time, a disturbance of the general
health.

The attempt has been made to divide these affections into two
varieties, according as the cause of the malady Hes in the organs of
chculation, or m those of respiration. In the first case the disease

64 SYMPTOMATIC PASSIVE HYPER.EMI^.

has been termed cyanosis, or morhus cmuleus (Blausuclit) ; in the
second^ pneumatelektasis (Sticksucht).

This classification has^ however^ found but few followers. The
changes in the skin are in each case the same, and the determining
cause can seldom, either during life or in the dead body, be so
isolated as to justify the setting up of this distinction between the
form of this affection due to cardiac, and that ascribed to pulmonary
disease. Hence the name cyanosis may be correctly applied to any
blue discoloration of the skin, which is caused by changes in the
circulation, and all these terms, cyanosis, morbus caruleus, cyanopa-
thia, atelectasia, ancematosis, maladie bleue (die blaue Krankheit,
Blausucht, Sticksucht), are to be regarded as synonymous.

Our forefathers looked on cyanosis as a peculiar and independent
disease, of which the immediate cause was either the mixing of
arterial and venous blood within the walls of the vessels, or some
impediment to the decarbonization of the venous blood. ^ Even in
more modern works^ we find the view expressed that the blood as-
sumes a " venous, cyanotic'^ appearance, when it does not meet in due
proportion with pure atmospheric air. These writers based their
opinion partly on the results of post-mortem examinations of the
bodies of those who are stated to have fallen victims to cyanosis.
Yarious congenital defects were, in fact, found in these cases :
patency of \\:it foramen ovale or ductus Botalli ; perforated or de-
fective septum ventriculorum ; hearts having but one ventricle;
absence, narrowing, or closure of the pulmonary artery or aorta ;
abnormal origin of the great vessels. The same view was, however,
also supported by cases of cyanosis, in which paroxysmal attacks of
dyspnoea occurred. These attacks, being followed by loss of con-
sciousness, convulsions, and foaming at the mouth, as well as by
blueness of the skin, affecting first the face, and j)articularly the lips,
and afterwards gradually involving the whole surface, led naturally
to the inference that the disease was one of a peculiar nature.

On the other hand, Rokitansky^ has fully proved, in detail, what
was before taught in part by Morgagni, Ferrus, Louis, and others,

1 'Beobaclituiif^en und anatomisch path. Erörterungen über die Blausucht:'
Yon Dr. M. Aberle, Prof. d. Anatomie zu Salzburg, in den Med. Jahrb. des
östr. Staates, Band 46, Neue Folge Band 37, Wien, 1S44, pp. i, 142.

- ' Lehrbuch der Path. Anatomie.' Von Prof. Dr. C._-E. Bock. Leipzig,
1847, p. 231.

3 'Handbuch der Path. Anatomie,' üB. Wien, 1844, p. 511.

SYMPTOMATIC PASSIVE IIYPERiEMI^. 65

that the cause of cyanosis always lies in the impeded passage of
venous blood into the heart, bj which a condition of stasis and an
engorgement of the capillaries are produced. Hence both the dura-
tion of the cyanosis and the degree to which it will be attended
bj other symptoms of disease will vary with the causes of the
obstruction to the venous blood. Among these may be the follow-
ing : — Organic changes in the heart, or in the large vessels ; as, for
example, extreme hypertrophy and dilatation of the heart with
valvular disease, want of correspondence in size between the heart
and the large vessels, &c. ; pulmonary affections, such as catarrh,
emphysema, bronchiectasis, pneumonia, compression of the limgs
by pleuritic exudation, &c., and, lastly, conditions of perverted
innervation, which are generally dependent on diseases of the brain.

The morbid appearances in the skin, resulting from these
causes, are as follows : — The surface has a leaden-gray, or even a
bluish-black hue, and this is most marked at those parts (such as
the lips, gums, cheeks, fingers, toes, &c.) which in healthy persons
are of a peculiarly bright or blood-red colour. The temperature of
the skin is lowered ; thus the thermometer sank in the hand of a
cyanotic patient of F. Nasse^ to 79' 2° Fahr. (21° R.) ; and this is
observed chiefly at the distal parts of the body, such as the hands,
feet, and face. Cold sweats also break out in these patients,
especially on the palms of the hands and the soles of the feet, and
lastly, dropsical swelHngs make their appearance.

These symptoms are either constant, merely becoming aggravated
from time to time as fresh attacks, attended by dyspnoea, set in ; or
they appear only in paroxysms, after which they vanish without
leaving behind tliem any traces of their presence.

There can obviously be no question of the treatment of cyanosis,
except in so far as we are able to cope with the morbid conditions
which give rise to it.

' 'Reil's Archiv,' B. x, p. 285.

CHAPTEE IV.

CLASS II.— AN^MI^ CUTANEA.

Morbid appearances of the Skin caused hy deficiency of Blood in the
cutaneous Capillaries.

Although no disease of the shin, in the ordinary sense of the
word, arises from deficiency in its blood-supply, yet an acquaintance
with the appearances which are caused by this condition is of great
importance, because it aids in the recognition of many affections of
the organism in general, and also because it leads to a correct inter-
pretation of certain changes, which an anaemic state of the system
may produce in the aspect of a pre-existing dermatonosis.

The appearances produced by anaemia of the skin are not in all
cases the same. Thus :

a. The colour of the skin will vary with the degree of physio-
logical pigmentation, and with the cause which gave rise to the
anaemia. If the integument contains but little pigment it will
assume a waxy appearance, especially if the loss of blood be sudden ;
wdiereas, when the deficient blood-supply arises gradually, and is the
result of previous wasting diseases, the skin will acquire a dirty,
pale-yellow tint.

On the other hand, parts of the integument which previously con-
tained excess of pigment, and, in the coloured races of mankind the
whole surface of the body, are made by anaemia, not paler, but
darker in colour. This may be attributed to the approximation of
the molecules of pigment in the epidermis, caused by the collapse
of the empty blood-vessels.

h. In reference to the natural turgidity and fulness of the skin,
caused by the infiltration of its tissue with fluid (Durchfeuchtuiig,
Wassergehalt), it may be remarked that this condition is diminished
in aneemia, both from the collapse of the vessels, and from the
absorption of the interstitial moisture, and that a change in the
aspect of the countenance is thereby produced.

AN^MI^. 67

c. The temperature of the surface falls when anseraia is rapidly
produced, but returns to the usual height if this condition persists
for some time ; and if a state of nervous excitement should become
developed in consequence of repeated haemorrhages, the temperature
may even rise some degrees above the normal level.^

d. The chief subjective symptom is a diminution of sensibility,
sometimes amounting to anaesthesia. Some patients also suffer from
cold shivering and shuddering, and others complain of a feeling of
pricking, and of increased warmth of the skin.

<?. The seat of the disease can, of course, be looked for only in
the vascular apparatus of the integument.

f. No particular eruptions appear as a result of deficient blood-
supply to the skin ; but a profuse cold sweat may mostly be observed
on the pale, colourless surface.

g. The course and duration of anaemia of the skin are various ;
it may be acute and transitory, or chronic and of long persistence.

h. Secondary appearances manifest themselves on the skin of
anaemic patients only when the morbid state has lasted for a con-
siderable time. It may then be observed that the horny structures,
such as the epidermis, hair, and nails, which are normally permeated
by fluid blastema, have become drier and more brittle, while emacia-
tion, and a peculiar loose state of the integument, are also produced
by the absorption of the fat from the subcutaneous areolar tissue.
Again, the deficient blood-supply to the skin causes not merely a
pallor of the surface, but also a diminution, or a complete drying up
of the secretions and of any exudations which were previously being
poured out. Lastly, in consequence of the smaller amount of fluid
permeating the skin, any parts of it which are hypertrophied, and
also all tumours or new growths decrease in size.

Anaemia of the skin may be divided naturally into two varieties,
according to its cause ; one form of it being produced by defective
blood-supply, and another by perverted innervation.

A. — Anemia of the Skin, from absolute want of Blood.

There are, as is well known, two ways in which the quantity of
blood in the body may be diminished ; this effect being sometimes

' 'Observations ou Bloodletting,' by Marshall Hall, M.D., 1836, p. 31.

68 ANiEMI^.

the result of haemorrhage, sometimes of certain states of disease^
attended by a slow wasting of the vital ilaid.

A. ANEMIA ARISING FROM HAEMORRHAGE.

Loss of blood, from injury to or rupture of the larger vessels^
is, usually, quickly followed by a condition of general ansemia.
This manifests itself for the most part, first by pallor of the
face, and especially of the lips, by coldness of the extremities, and
cold sweats. These symptoms are afterwards accompanied by
signs of depression of the nervous system — such as the appear-
ance of mists before the eyes, failing of the senses, trembling, loss
of power to maintain the body erect, nausea, sickness, &c. These
phenomena constitute the condition of syncope (Ohnmacht) ;
which, if the loss of blood continues, and if the nervous centres
become paralysed, passes into one of apparent death (Scheintod),
and ultimately into death itself — in which case the appearance of
the skin remains unchanged in the dead body. The expression
*' cadaveric hue," (Leichenblässe, Cadaveröses Aussehen, Todteu-
farbe, &c.) has, in fact, partially lost its original meaning, and
serves likewise for the description of the appearances produced in
the Hving skin by ansemia. Besides the pallor of the lips and
mucous membranes generally, and of the skin (the first striking symp-
tom of syncope), the anaemic condition of the surface is further
shown by the fact, that no blood flows from recent wounds so long
as the patient is in a fainting state, although they may have bled
freely before and may again bleed afterwards.

B. ANiEMIA CONSEQUENT UPON DISEASE.

All diseased states of the human organism, in which the due
relation is not preserved between the renewal of the blood and its
consumption, so that more of the vital fluid is expended than is
during the same period reproduced, give rise at last to a condition
which, besides other appearances, manifests itself in a pale, dingy,
earthy, or dirty-yellow look of the skin, called by the name of
ohgsemia or anaemia. Thus, in patients convalescing from pro-
longed febrile complamts, we see the same pale and eai-thy appear-
ance of the skin as in those who suffer from advanced tuberculosis,
syphilis, scorbutus, carcinoma, chlorosis, &c. At the same time,
the sl^in may generally be noticed to have a greasy feel, resulting

AN^MIiE. 69

from an increased secretion of fat by the sebaceous glands, as well
as from changes in the formation of the epidermis. This con-
dition and the presence of numerous white branny scales con-
stitute an affection to which writers have given the names pity-
riasis tabescentium, phtJdsicorum, scro^ihulosomm, &c. Another
symptom, also, which has the same origin, is the falling off of the
hair {Defluvium cajnUorum), which in most cases accompanies this
form of ausemia.

B, — Anemia op the Skin, caused by Perverted Innervation.

Various influences may so affect the nervous system as to give
rise to an anaemic condition of the skin, in addition to all sorts of
other symptoms. Fear, distress, anger, indignation, frequently pro-
duce pallor of the face, which arises suddenly, mostly lasts somewhat
longer than the mental disturbance by which it was caused, and
terminates without any further consequences in the return of the
normal colour of the skin. So also fainting, whatever may be its
cause, makes the whole surface of the body pale, and, as I have
already stated, leads to a suspension of haemorrhage.

A knowledge of anaemia of the skin, and of the group of symp-
toms to which this gives rise, affords an explanation of certain
peciüiar appearances, and often enables us to interpret them in a
way quite different from what has hitherto been done.

The pallor of the skin, resulting from imperfect injection of the
capillaries, will, of course, whatever may be its cause, show itself
not less in those who suffer besides from some cutaneous disease,
than in those whose skins are otherwise healthy. But if this
skin-affection be one of those which manifest themselves chiefly by
a vascular injection and redness of the surface, it is clear that no
trace of it will be seen, so long as the anaemia persists.

Por the same reason, on the dead body certain appearances of the
skin alone remain visible. Such are those which arise from changes
in the structure of the different tissues of the skhi (as, for example,
the thickening of the epidermis in tylosis, ichthyosis, &c., and that
of the cutis in pachydermis, keloid, elephantiasis Graecorum, &c.) ;
and those which are due to the presence of morbid products (such
as scales, crusts, pigmental deposits, parasitic growths, &c.) deposited
on the surface of the skin, or infiltrating its tissues. The only mere
reddenings of the surface, which are to be seen in the dead body,
are those which are caused by extravasation of blood, or by the pre-

70 ANiEMI^.

sence of inflammatory exudation in large quantity. On the other hand,
all those rashes which arise merely from hypereemia, or accompany
the less severe exudative processes, disappear altogether after death.

Hence, it is not surprising that in those who have died of
morbilli, scarlatina, or erysipelas, the skin presents a colour alto-
gether different from that seen during life. It is also in vain that
one looks in the dead body of a patient who suffered from psoriasis,
eczema, or lichen, for the numberless bright-red spots which existed
on the surface of his skin while he was alive. Unless their position
is betrayed by the presence of scales, or of pigment, it is not possible
to demonstrate the existence of these eruptions after death.

As this is what becomes in the dead subject of skin dis-
eases which were present during life, we shall not be astonished to
observe the same thing in the living patient, whose skin, like that
of a corpse, is in an ansemic state.

Hence, when syncope suddenly occurs, we find that those derma-
toses vanish which manifested their presence by reddening of the
skin; and, as consciousness returns, they also reappear. For the
same reason, parts of the skin which had been reddened, become
pale during the last struggle for life.

A similar influence upon various forms of skin-affection is pro-
duced also by the antemia caused by loss of blood, and that
whether this state is developed rapidly as a result of haemorrhage,
or slowly from excessive consumption of the blood in its circulation
through the body. Hence, chronic skin complaints disappear when
prolonged febrile diseases of the organism such as pneumonia,
typhus, &c., have caused a diminution in the quantity of the vital
fluid, and this occurs in proportion to the advance of the general
disease. Thus it is that we find chronic dermatoses alternating with
acute affections of internal organs, disappearing during the course of
these complaints, and showing themselves anew while convalescence
is in progress. We never observe the reverse, that is to say,
that the skin disease vanishes first, and that the visceral affection
occurs afterwards as a result of its disappearance. The idea that
this might take place had formerly, as is well known, very many,
and has unfortunately even now some, supporters, and gave rise to
the doctrine of the liability to metastasis of chronic skin affection,
a doctrine utterly without foundation.

CHAPTER V.

CLASS III.— ANOMALIE SECRETIONIS GLANDULARUM
CUTANEARUM.

Diseases due to perverted states of the Secretions of the Cutaneous

Glands.

The affections belonging to this class are of two kinds — the first
group including the various functional disorders of the cutaneous
glands ; the second, their structural diseases. These last, however,
concern the sebaceous glands alone, of the two varieties of secreting
organs contained in the skin; for, up to the present time, the
sudoriparous glands have not been shown to be subject to any such
structural affections.

Now, I propose, in the first place, to describe those morbid
conditions of the cutaneous glands which affect the functional activity
of these organs. But before doing so I must define the position
which I take up in reference to these disorders.

This is not the place to point out the important effects on the
system generally which must be produced by any excess or dimi-
nution in the secretory activity of the cutaneous glands. My chief
object must rather be to describe those morbid conditions of the skin
to which a perverted state of their functions often gives rise. Hence
the present subject naturally divides itself into two parts. I must
first describe the morbid changes in the secretions themselves ; and,
afterwards, the cutaneous affections which result from those changes.

Before referring specially to the sweat and the sebum (the two
secretions which are found in and upon the surface of the skin), it
may be well that I should draw attention to the fact that these sub-
stances can be regarded as existing separately from one another, only
when one of the two can be plainly recognised by its own pecu-
liar characters. Slight variations in their proportionate quantity
can scarcely, if at all, be detected. In the healthy state the

72 AFFECTIONS OF THE GLANDULAR SECRETIONS OF THE SKIN.

jiroducts of both kinds of glands reach the surface of the integument
in a more or less aeriform condition. Among other purposes, they
serve to moisten, polish, and lubricate the skin. When secreted
together in the normal way, they constitute a vaporous exhalation,
which cannot properly be regarded as either sweat or sebaceous
matter, but is really a combination of them both. With the
addition of the fluids and gases which are poured forth by the vessels
of the papillse themselves (independently of any glandular organs),
and which pass through the epidermis, the exhalation before alluded
to is what has been termed by physiologists the materia perspiratoria.
The fact that the secretions of the sudoriparous and sebaceous
glands are poured out simultaneously upon the surface of the skin,
and there mixed together, has hitherto thrown great difficulties in
the way of all attempts to determine the normal microscopical- or
chemical characters of either of these products. Indeed, none of the
analyses hitherto made can be supposed to be absolutely correct.

Those who have investigated the composition of these substances
have adopted various methods, but have never succeeded perfectly in
separating from one another the secretions of these two kinds of glands.
Thenard, in his experiments, made use of shirts, saturated with perspi-
ration; Auselmino collected the secretion by enclosing some part of the
body in a cylindrical tube of glass ; Schottin, with a similar object,
washed the surface of the skin after death. No satisfactory results,
however, were obtained by any one of these procedures ; nor did any
better success attend Seguin^s method of employing silk, covered on the
outer surface with caoutchouc, to absorb the perspiratory secretion;
or the attempts of Tunke and Favre to collect the sweat from a
person placed in a vapour bath, and made to lie on a metal sur-
face hollowed towards the centre. Whatever plan they may have
adopted, experimenters have obtained, not the pure secretion of the
sudoriparous gland«, but a mixture of this and sebum, containing
also detached epidermic scales and condensed vaporous exhalations.
Moreover, the artificial conditions under which such investigations
are made necessarily introduce further errors into their results, by
altering the quantity of the cutaneous secretions.

Thus, then, the statements of different authors with reference to
the quantity and composition of the glandular secretions of the
skin have only a subordinate value. This is, indeed, confessed
by Ludwig, Henle, Lehmann, Valentin, Kölliker, and other
physiologists.

AFFECTIONS OF THE GLANDULAR SECRETIONS OF THE SKIN. 73

As for the chemical constitution of the sweat, those who have
analysed this fluid assert that it contains from 99*30 to 99*55 per cent,
of water, the residue consisting of sohd matters, among which are
chloride of sodium, phosphate of hme, hydroclilorate of ammonia,
and traces of iron and of fatty matters. Favre, for example, gives,
as the soHd substances contained in this secretion, chloride of sodium,
chloride of potassium, sulphate of potass, phosphate of soda, earthy
phosphates, albuminate of potass, lactate of potass, a potass-salt
containing a peculiar acid (Schweisssaueres Kali), urea, and fat.

Schottin,! again, analysed the perspiration of the feet, and found
in a hundred parts of this fluid 0*05 of insoluble, 0*84 of soluble
matters. These consisted of —

Phosphate of lime

. 0037

Phosphate of magnesia

• 0013

Chlorine ....

• 0279

Sulphuric acid .

. 0049

Phosphoric acid

. 0020

Sodium ....

• o'25i

Potassium

. o"099

It is, however, necessary to bear in mind, that great variations in
the quantity and quality of the cutaneous secretions occur normally
even in the same individual, and still more in different persons,
although apparently in good health and of simuar constitution.
These variations could not be in any way taken into account in the
analyses I have quoted; and this fact may be given as another
reason for the great differences in the results obtained by so eminent
observers, in addition to the difficulty (to which I have already
referred) of isolating these secretions, and analysing them separately.
Hence it appears to me that the distinctions between the different
diseases of the skin, caused by morbid conditions of its glandular
organs, must not be made to depend upon chemical analyses, such
as those of which I have been speaking. The characters of the
affection must in each case be regarded from a clinical point of view,
and its definition must be based on the mode of succession of the
symptoms, that is to say, upon the course of the disease.

From this stand-point, then, I shall endeavour to deal with the
subject before me.

1 * De Sudore,' diss, inaug., Lipsiae, 1851.

74 AFFECTIONS OF THE MATERIA PERSPIRATORIA.

The affections produced by functional disorder of the glandular
organs of the skin may be divided into three groups, according to
the nature of the morbid products which present themselves.
First, there are diseases of which it cannot be positively stated
whether they arise from a perverted activity of the sudoriparous or
of the sebaceous glands, or even of the papillse of the cutis. The
substance which appears on the surface of the skin is, in these cases,
what would in the normal condition be termed, as a whole, the
materia persplratona. Secondly, there are affections which are
attended with the formation of a watery fluid in large quantity, due
principally to the action of the sweat-glands. Lastly, there are
conditions in which the secretion is shown to be the product of the
sebaceous glands, not only by its peculiar nature, but also by the
position which it occupies.

A. — Affections produced by morbid states op the Materia
Perspiratoria.

The conditions which come under this head are principally those
in which our sense of smell is powerfully and disagreeably affected
by exhalations possessing a specific odour, Even in the normal
state each human being probably diffuses around him a special
odour, although this is not strikingly perceptible to our senses.
Animals, such as dogs, whose power of smell is acute, are well known
to recognise their master by this sense rather than by that of sight ;
and it is also a fact that persons still uncivilised, such as negroes
and Indians, are able to scent friends or foes from a distance.

But even on the imperfect sense of smeU possessed by ourselves
certain persons produce a disagreeable impression; and there are
those who, in spite of the most scrupulous cleanliness, cannot remove
the specific evil odour which clings to them. Now, it cannot be main-
tained that this unpleasant smell belongs exclusively to the perspiratory
secretion. On the contrary, the odours observed in these cases
generally resemble those of the fatty acids, substances which are
certainly formed in much larger proportion by the sebaceous than
by the sudoriparous glands.

Hence, I am not disposed to ascribe to a morbid state of the
sweat alone the disease which is spoken of by authors under the
name of Bromidrosis {Osmidrosis, stinkender Sch weiss). I regard it

BROMIDROSIS. 75

as resulting rather from an abnormal condition of the materia per-
spiratoria, that is^ of the cutaneous exhalation as a whole.

In these cases of bromidrosis the disease, as is well known, may
either be universal, affecting the whole cutaneous surface, or confined
to some particular part of the skin. Hence, if we would adhere to
the old terminology, we must divide this complaint into a B. uni-
versalis and a B. localis.

{a) Bromidrosis universalis.

Under this head are to be reckoned those cases in which there
arises from the surface of the skin a fetid exhalation, of which we
cannot indicate the special source, the patient being at the time in a
healthy state, and the cutaneous secretion not being particularly
increased in quantity, or, at any rate, not collecting in the form
of drops.

If a person remains continuously in an atmosphere which is im-
pregnated with any substance having a specific odour, this wül, of
course, adhere mechanically to his clothes, skin, and hair. But, at
the same time, he will inhale these odorous matters suspended in
the air, and therefore must also exhale them through the agency of the
cutaneous organs, namely, the sweat-glands, sebaceous glands, and
papillae. This is proved by* what we observe in those who have, for
a long period, been placed under such conditions. However fre-
quently and thoroughly such persons may endeavour to cleanse them-
selves, it is only after the lapse of a considerable time that they
lose the subjective sensation of the peculiar smell, and cease to give
off from the skin a similar odour.

There have, indeed, been physicians, who, with Heim, of Berlin,
have maintained, not only that each one of the exanthemata possesses
a specific smell, but also that they could detect it so constantly and
with, such precision as to be in the enviable position of being able,
by means of this odour, to distinguish these diseases from one
another. Thus, it has been asserted that patients affected with
morbilli exhale an odour like that of recently plucked feathers;
that in scarlatina the smeU resembles that of new bread ; in small-
pox, that of a menagerie; in the disease termed " Friesel,"^ that of
decomposing straw. But the organ of smell must surely be extra-

^ This disease is fully described by Prof. Hebra under the name of " miliaria "
in a later chapter of this work, among the acute, non-contagious, exudative
dermatoses. — [£d.]

76 AFFECTIONS OF THE MATERIA PERSPIRATORIA.

ordinarily acute to be able to detect these odours ; and in any case
they have no claim to be termed characteristic, for the substances
with which they are compared by no means possess a smell so decided
as to prevent the possibility of confounding them with many others.

(b) Bromidrosis localis.

Among the parts of the skin from which disagreeable odours most
frequently arise must first be mentioned the axillae. In these regions,
as is well known, there exist large glandular bodies, which bear a
general resemblance in their structure to the sweat-glands, but have
been termed by some ceruminous glands, from their being still more
like those which are found in the external auditory meatus, and
secrete the cerumen. The true character of these organs is doubtful,
it being still a matter of dispute whether they should be reckoned
among the sebaceous or rather among the sudoriparous glands.

The male and female genitals, the perinseum, the neighbourhood
of the anus, the soles of the feet, and particularly the lateral surfaces
of the toes, must also be mentioned as liable to give off intense
odours of a similar kind.

In each of these regions the secretion of the skin has, normally,
a disagreeable smell, and, under certain circumstances, may be so
increased in quantity and changed in character, that its altered con-
dition is, in itself, a disease. Moreover, this fluid then gives rise to
an unhealthy state of the skin over which it flows ; the appearance
thus produced being sometimes merely a reddening and maceration
of the epidermis, or, in other words, an intertrigo ; whereas, in other
cases, it amounts to an actual eruption, of a papular, vesicular, or
bullous character, and, in fact, presents all the symptoms of an eczema.

So far as the bromidrosis pedum is specially concerned, this arises
from the extraordinary quantity of the cutaneous secretion which is
poured out, rather than from its being, when first formed, par-
ticularly altered in composition. Obviously, therefore, the foetor
will become more intense as the amount of this fluid increases;
for if we compare the smell of the ordinary cutaneous secretion of the
feet with that of the so-caUed unhealthy perspiration, we find that
these odours differ, not in their quality, but merely in their intensity,
which, in fact, rises and falls with the changes in the quantity of the
fluid poured out. In the normal state the smell can be perceived
only when the nose is brought close to the person^s foot ; under
morbid conditions it is noticed even at a distance.

BROMIDROSIS. 77

But^ however much the sweat may in such a case be increased in
quantity^ it will be found, on investigation, that this fluid is not in
reality the only source of the evil odour given off by the cutaneous
secretion. On the contrary, this smell arises from the presence of
a large proportion of fatty matters, the product of sebaceous glands
which exist abundantly on the sides of the toes and also on the
dorsal surface of the foot. When this secretion is first formed,
however, no disagreeable odour belongs to it any more than to that
of the sweat-glands or to the exhalation of the papillse. The smell
arises only when the fluid has remained for some time on the sur-
face of the skin, and especially when it has undergone decomposition,
its evaporation having been prevented by the coverings worn on the
feet. As I have already stated, this secretion contains fatty matters
in large quantity. These, of course, tend to undergo those changes
to which all such substances are liable, consisting in the formation
of the well-known series of fatty acids, among which are the caproic
and the caprylic. This decomposition, which is favoured by the
warmth and moisture of the parts, gives to the perspiration the smell
characteristic of these acids.

These changes occur even under normal conditions, but to a far
greater extent when the secretion from the feet is excessive, so as to
saturate the shoes and the socks or stockings of the patient. And
it is obvious that the more often these articles are soaked with per-
spiration, and the longer they are worn without being changed, the
more intensely will they become impregnated with tliis odour, which
they will communicate to the air around.

That this is really the case any one may prove by taking a person
who suffers from this complaint, removing his ordinary shoes and
stockings, and making him wash his feet thorouglily several times,
and lie in bed for a few days. If, at the end of this time, the smell
of the things which were laid aside be compared with that of the feet,
it will be found that the latter, even though they may have become
covered with sweat beneath the bed-clothes, no longer give off the
disagreeable odour which still adheres powerfully to the shoes and
stockings.

It is clear, then, from what has been stated, that there is not, pro-
perly speaking, any disease in which the secretion of the feet is fetid,
but that there is an affection in which this fluid is formed in excessive
quantity, and afterwards acquires an evil odour as a result of its de-
composition.

78 AFFECTIONS OF THE SECRETION OF THE SWEAT-GLANDS.

Hence there is obviously no foundation whatever for the absurd
fancies which formerly prevailed as to the usefulness or injuriousness
of this fetid secretion, or as to the ill-effects of its suppression,
by which various other diseases were supposed to be produced.

B. — Affections caused by Functional Disorder of the
Sudoriparous Glands.

(i) Quantitative Changes in this Secretion.

A. Hyperidrosis.

a. Hyperidrosis universalis.

Under the name of hyperidrosis is to be understood that con-
dition of the skin in which the secretion of the sudoriparous glands
appears as a fluid in the form of drops, and does not entirely pass off
in a vaporous state, as is normally the case. The use of this term
should, however, be restricted to those instances in which such an
accumulation of the sweat occurs under conditions in which it would
not naturally be observed, or, at any rate, would be but slight ; so
that the excessive secretion is in itself to be regarded as morbid, and
the more so because it also gives rise to certain secondary affections
of the skin.

It is obvious that in this place I cannot attempt to describe those
forms of hyperidrosis (Schweisssucht) due to the presence of some
other disease, of which sweating is one of the regular symptoms, or
in which it is often present.

Thus, I shall make no further mention of the non-febrile chronic
ephidrosis of Schönlein,^ or of the colliquative sweats of phthisical
patients, or of the so-called " critical" sweats which occur in acute
febrile diseases, such as typhus and the exanthemata. Nor shall I
give an account of the " suette de Picardie,"^ an affection which
appeared in Picardy in 17 18, or of the "sudor Änglicus,"^ another
of these complaints, which broke out in the army of Henry VII in
1485, and is said to have raged in England, Prance, and Germany,
on five separate occasions between 1485 and 1550. I shall concern
myself with hyperidrosis only from the dermatological stand-point,
describing those affections alone which simply consist in a perverted

1 Scliönlein's 'Path. u. Ther., nach dessen Vorlesungen, von einigen seiner
Zuhörer herausgegebeu,' vol. iii, p. 142. St. Gallen, 1841.

^ Ozanam, 'Mal. epidein.,' vol. i, p. 222. Paris et Lyons, 1835.
^ Ibid., vol. iv, p. 93.

HYPERIDROSIS UNIVERSALIS. 79

state of the perspiratory function or are caused by the local action
upon the skin of sweat already secreted.

Now, it is well known that some indi\dduals perspire under cir-
cumstances under which the skin of other persons remains perfectly
dry, and yet that this form of hyperidrosis leads to no ill-effects
on either the general health or the other functions of the body.
Examples of this are far from being rare, either in medical litera-
ture or in our daily experience. The persons who thus "melt"
(zerfliessen) into perspiration, on the slightest bodily exertion or
movement, are generally stout, well-nourished, and inchned to be
fat, possessing a good digestion and an equally good appetite both
for solids and fluids.

Again, there are others who likewise sweat enormously, but only
under the influence of a high temperature, as when they are exposed
to the rays of the sun or to some artificial source of intense heat.
This is observed, for instance, in the inhabitants of southern
cUmates, and also in the case of stokers, glass-blowers, and men
who follow certain other occupations.

Now, in many individuals, this exalted activity on the part of the
perspiratory glands leads to no morbid change in the vital condition
of the skin (in dem Hautleben) ; but in others it gives rise to an
efflorescence exactly similar, both in form and colour, to those
eruptions which are well known to be produced by the action of
various irritants. This efflorescence generally consists of small red
papules, seated chiefly at the apertures of the cutaneous glands.
Vesicles also are occasionally present, and these may even contain a
puriform fluid, being, in reality, small pustules. All these are at
first isolated from one another, and it is only when the rash has been
of long duration that they coalesce, so as to form large continuous
patches.

These appearances have received diff'erent names, according to the
cause which gives rise to them. When they are observed on the
skin of persons otherwise healthy, in whom the cutaneous sur-
face is covered with drops of sweat, they are called sudamina.
"When met with in southern climates they are termed calori ; and
other names, all belonging to the same affection, are the "lichen
tropicus'' of Willan, the " sesh" of Cleghorn, the "prickly heat" of
English, antl the " Hitzblätter chen" of German writers.

In their form, extent, and seat, and also in the course which they
take, these eruptions are altogether similar to those which we can

80 AFFECTIONS OF THE SECRETION OF THE SWEAT-GLANDS.

generate artificially by the application to the skin of various irri-
tants. Thus, the action of hot or cold water, in the form of baths,
fomentations, or lotions, gives rise to affections to which the
name " psyclracia thermalis" was formerly applied, and which
more recently, when caused by the hydropathic mode of treatment,
have been regarded as indicative of crises (Hautkrisen). They are,
in fact, artificial forms of eczema, and with them, as I have said,
the disease which I am now describing is perfectly identical.

Hence it would in reality be better to use the name eczema to
designate these papular and vesicular eruptions due to hyperidrosis,
some epithet, such as " sudamen," being added. Thus, they might
receive the common appellation of eczema sudamen. The name
sudamina^ however, has hitherto been generally given to these affec-
tions, and the other terms which I have quoted have also a cer-
tain claim to be noticed, being employed in various works ; I have
therefore been obliged to refer to them ; but I may, finally,
again remark that all these appellations — sudamina, calori, miliaria
rubra, &c. — belong to one and the same eruption, which accom-
panies profuse sweating.

This is shown by the fact that, when such an efflorescence has
lasted for some time, the appearances presented by it are in every
respect identical with those of any other form of eczema, whether
originally produced by the action of some cutaneous irritant or even
by a morbid condition of the system generally.

He who is acquainted with the various stages, through which an
eczema passes, will recognise all of them in the so-called " suda-
mina," the eruptions caused by excessive sweating. This is parti-
cularly the case when the perspiration goes on without cessation
both by day and night, as in those who live in tropical climates, or
follow certain occupations. The same thing, however, may be ob-
served also when these forms of efflorescence, being regarded as
*' crises," and therefore as desirable, are aggravated by methods of
treatment supposed to be judicious, but which are, in reahty, quite
the contrary.

In this way it might often happen that the most severe varieties
of Eczema rubrum and E. impetiginosum should be generated from

1 It is scarcely necessary to remark that this terra is generally used by
English writers in a dififerent sense. The eruption consisting of transparent
vesicles, commonly termed " sudamina" in this country, is described by Prof.
Hebra under the name of Miliaria. — [Ed.]

HYPERIDROSIS UNIVERSALIS. 81

eruptions which were originally mere "sudamina." To produce
this result we have only to excite the cutaneous glands still further,
by making the patient wear warm clothing, giving him hot drinks,
and keeping him in a heated atmosphere. Even the application to
the skin of stimulating ointments, or the use of warm or cold
baths, which likewise act as local irritants, may in these cases be
sufficient to convert a simple papular or vesicular eczema into one
of the more intense forms of this disease.

But if, in such a case, the temperature of the skin is no longer
raised above the normal level, and if the excessive perspiration con-
sequently ceases, the eruption will shortly fade; some of i\\e papules
will become covered with mfnute scales of detached epidermis ; the
itching will diminish, and the integument will gradually return to
the healthy state, presenting at last no trace of the disease with which
it was affected. But even when sudamina thus subside, instead of
passing into more severe affections (as they do when irritated), the
course which they take still shows their identity with the eczemata.

Authors have propounded different views with reference to the
mode of development of these eruptions due to excessive sweating.
Some think that the fluid, being exhaled over the whole surface
of the skin by the papillae, and not merely by the sudoriparous glands,
accumulates beneath the epidermis, and raises it into papules
or vesicles. Others consider the mouths of the sweat-glands to be
the seat of the vesicles, attributing them to the fact that the spiral
ducts of these glands open very obliquely. Others, lastly, think
that the sweat, when formed, is an irritant to the skin, and acts like
any other irritant applied to its external surface, and they regard
sudamina as the result of this action.

Careful observation of this affection shows, however, that the
papules and vesicles are not caused by the action of the sweat after
its secretion, but arise, if not before the perspiration occurs, at least
simultaneously with its first appearance.

Thus, there are some individuals who, when affected with profuse
sweating, are liable to become covered in a few hours, for instance,
in the course of a single night, with an enormous quantity of
sudamina. In certain persons, on the other hand, some parts of
the skin are for years almost continually covered with perspiration,
without any sudamina or, indeed, any eruption whatever, being
formed. This is the case with most of us, so far as the skin of
the axillae, nates, and genital organs is concerned. The sweat does,

82 AFFECTIONS OF THE SECRETION OF THE SWEAT-GLANDS.

indeed^ like any other warm fluids act injuriously on those parts of the
skin with which it comes into contact. But it is the epidermis which
first suffers from this action, and only when this has been mace-
rated and softened can the subjacent corium be in any way affected
by it.

I am, therefore, inclined to regard sudamina as caused, not so
much by the perspiration already poured out upon the surface of the
skin, as by the hypersemic state of the cutis, and the consequent eleva-
tion of temperature, whicli precede the secretion of that fluid. The
vessels which aid in the formation of the sweat include those which
supply the papillae, as well as those which enclose, in their meshes,
the sudoriparous and sebaceous glands ; 'the whole network of capil-
lary vessels in and beneath the skin being, in fact, concerned in the act
of secretion. Hence the perspiratory fluid, being everywhere poured
out in excessive quantity, and collecting beneath the epidermis,
raises it in the form of papules or vesicles, while at the same time
the papillae themselves become reddened and swollen.

A proof of the correctness of this view is surely furnished by the
fact that the patient complains of a transient pricking sensation in
the skin, while the sudamina are being developed. This could
hardly be explained if the only structures concerned were the sudo-
riparous glands, which certainly are not known to be very sensitive
organs. But these precursory feelings of pricking and formication,
often amounting even to intense itching, are sensations which are
likewise observed in other affections of the cutaneous papillae. The
English name, " prickly heat/^ appears to have reference to these
subjective symptoms.

Treatment. — Although medical advice is not sought in very many
cases of sudamina, there are yet some more severe forms of this
affection which are brought under the observation of the physician,
either because they are mistaken for other diseases, or because the
patient is annoyed by the sensations of pricking, formication, or
itching, with which they are attended.

Now, when we are able to lessen or stop altogether the exposure
of the patient to the action of heat, there will be no further diffi-
culty in reheving him of his complaint. But this cannot always be
done. It is often impossible for him to withdraw himself from the
operation of the agencies which set up the disease.

Under such circumstances we must at any rate avoid aggravating

HTPERIDROSIS LOCALIS. 83

the affection by injudicious treatment. Above all, we must not
allow the patient to take baths. "Warm baths are particularly
injurious, and we must dissuade him from using them^ even though,
as is generally the case, he may urgently demand from us permis-
sion to do so. It is also of great importance that we should give
up the old idea that these eruptions must not be rapidly " driven
in," on account of the danger that metastasis should occur. In
fact, it should be our firm conviction that we ought to do all in our
power to prevent the appearance of fresh sudamina. Lastly, we must
be especially careful not to irritate the skin, for irritation of any kind
may cause a shght form of this rash to undergo further develop-
ment, and lead to the production of new papules or vesicles.

In many cases the avoidance of all fresh causes of irritation will
be sufficient to relieve or even cure the patient. But it is necessary
to remember that all fatty and oily substances, as well as ointments
containing these substances, act as irritants to the skin of many indi-
viduals. In the management of this affection, therefore, we must
carefully avoid all such applications, besides forbidding the patient to
employ baths, which, as I have already stated, are also very injurious.
A purely expectant mode of treatment, provided the skin be kept
cool and dry, will in most cases lead to the involution of the disease.
The bed- and body-linen should, however, be frequently changed,
especially things which have been soaked with perspiration -, and
some pulverulent substance, such as starch, lycopodium, or pow-
dered asbestos, may be applied locally as an auxiliary remedy.

ß. Hyperidrosis localis.

When the perspiratory secretion of any part of the body is in-
creased the surface of that region will obviously feel moist and cool.
But, further, if the sweating continues, we find that certain injurious
effects are produced by the local action of the perspired fluid on the
skin. Under such circumstances the epidermis, being saturated
with sweat, presents the same appearance as when it has, for a long
time, been acted upon by any other warm fluid. Its condition is, in
fact, identical with that produced by a warm bath. Thus, on the
palms of the hands and the soles of the feet the skin becomes
wrinkled, and assumes a white colour, its most superficial layer
becoming soaked and softened; so as to be readily detached by rubbing.

84 AFFECTIONS OF THE SECRETION OF THE SWEAT-GLANDS.

In other regions, however, as, for example, on the scalp and on the
surface of the axillae and genitals, this condition is not observed,
even when the skin has for a long time been exposed to the local
action of the perspiration. At these parts, the surface remaining, as
already stated, moist and cool, a more or less intense reddening of
the skin is produced, and the horny stratum of the epidermis becomes
partially removed. This affection is, in fact, that which is termed
intertrigo (Fratt) . Sometimes, however, the ordinary eruption, which
I have described under the name of sudamina, arises in these cases.

In conclusion, I must not omit to refer to the cases, cited by
several authors^, of perspiration occurring on only one side of the
body. This affection has sometimes been general, sometimes par-
tial. Thus it has occupied only one cheek,^ or one hypochondrium
(Dolens) ; or one side of the abdomen, chest, or back of the neck ; or
even one upper or lower limb. I have never myself had occasion
to see a case of this kind ; but I am not disposed to doubt the cor-
rectness of the statements made by the writers above referred to, or
to deny the possibility that such anomalous affections of the perspi-
ratory glands may sometimes occur. Indeed, we could, at the
present day, give an explanation of them by referring them to a
morbid state of the local innervation.

Many writers of good repute, such as Ledel, Frommann, Lanzoni,
Paulini, Helwich, and Speranza, are quoted by Jos. Frank, ^ as hav-
ing asserted that they had seen sweat formed after death. I cannot,
however, admit the truth of so extraordinary a statement, for, indeed,
such an occurrence is physically impossible. It appears to me that
the mistake arose from the fact that a corpse was sometimes found
to be wet. This fact, however, may be explained by referring it to
the well-known circumstance that cold bodies, when placed in air
which is at a higher temperature, condense watery vapour upon their
surface, and therefore become moist. For instance, a deposit of

' Trancus de Eranckenau, ' De sudore unius tautum lateris, c. addendis,'
G. Detharding ('Miscell. Acad. Nat. Cur./ Dec. i, A. 4 et 5, 1673 et 1674,
p. 103; Cent, i et ii, Append., p. 188). J. Schinid (ib., Dec. ii, A. 2, 1683,
p. 287). P. Rommel (ib., Dec. ii, A. 10, 1691, p. 376). S. Lcdel (ib., Dec. iii,

A. 2, 1694, p. 62). B. T. Otto Hannemanu (ib., Dec. iii, A. 5 et 6, 1697,
1698, p. 461). Bichat, 'Anatomie Generale,' Paris, 1812, t. iv, p. 703.

B. Roque, ' Observateur des Sciences Medicales,' Avril, 1823. Jos. Frank,
'Hautkrankheiten,' iii Theil, p. 312, Leipzig, 1843.

' Kostreraski, * Memoires de Paris,' 1740, Hist., p. 51.
^ Op. cit., Band iii, p. 317.

HYPERIDROSIS LOCALIS. 85

moisture is formed dui'ing winter on the window-panes of a M'arm
room.

The forms of local sweating which are of most interest, from a
dermatological point of view, are those which affect the axillae, the
genital organs, the palms of the hands, and the soles of the feet.
For in these regions there are often produced morbid appearances
which may easily be misunderstood, and wrongly explained, by those
who have but an imperfect knowledge of the physiological and
pathological changes to which the skin is liable. Indeed, the
literature of the subject shows that these diseases have frequently
been supposed to be more serious than they really are.

The effects of hyperidrosis may, in fact, present themselves in a
somewhat more intense form than has hitherto been described, and
then no longer consist in a mere reddening of the surface, or in the
production of papules or vesicles, attended with but little discomfort
to the patient. On the contrary, they sometimes pass into severe
cutaneous affections, which are in no way distinguishable from those
forms of eczema caused by other local irritants. In other words,
tlie Hyperidrosis localis may give rise to eczema in all its grades.
To this point I shall again have occasion to refer when speaking of
the etiology of eczema.

Hence, when simple eczema, or even E. rubrum or E. im-
petiginosum, presents itself in the axillse, on the scrotum, on the
inner surface of the thighs, or round the anus, we must always
bear in mind the possibiHty that the affection may have been caused
by a perverted state of the local perspiratory function.

I have, however, never seen the palms of the hands or the soles
of the feet attacked with eczema, as a result of hyperidrosis. The
palms of the hands, indeed, are never in any way affected by the
secretion of sweat upon their surface, merely feeling unusually damp
and cold. In some cases, also, no further changes are produced in
the soles of the feet ; but in other instances, particularly when the
excessive perspiration has lasted a long time, the cuticle of these parts
becomes softened, and partially cast off. This gives rise to a very
painful condition of the tracts of skin thus deprived of their
covering. The tenderness is, indeed, sometimes so extreme that
the patient cannot walk or even stand, and can wear neither shoes nor
boots, so that he is obliged to keep his bed.

Thus, the Hyperidrosis localis, a disease which is in itself of very
little importance, may in certain cases be very disagreeable to the

86 AFFECTIONS OF THE SECRETION OF THE SWEAT-GLANDS.

person suffering from it^ not only on account of the pain which it
produces, but also because it interferes with his earning his living.
All that needs be said in reference to the smell of the perspiration
in these affections has already been fully described under the head of
Broraidrosis.

When we have occasion to observe one of these cases for a con-
siderable time we often find that the cutaneous affections caused by
the excessive perspiration ultimately subside, giving rise to no
further injurious effects, so far as the skin is concerned. Sometimes,
however, they pass into an intertrigo, or into sudamina, or even into
an eczema. In this case the disease so produced takes the ordinary
and well-known course of other forms of the affection. Lastly, when
the hands or feet are the parts affected, the only appearances to be
observed are those changes in the epidermis which have abeady been
more than once described.

These different affections, having once developed themselves, and
reached a certain degree of intensity, do not afterwards undergo any
changes of importance, but remain stationary so long as their exciting
cause continues. They do not in any vvay affect the general system ;
so that, on the one hand, pre-existing diseases are not cured, or even
relieved, by the appearance of a local hyperidrosis ; and, on the other
hand, the subsidence of the swelling does not lead to the develop-
ment of any fresh malady. It has, indeed, been supposed that such
effects have been produced ; but it is probable that, in most of these
cases, an error of observation was made, from the complaint having
been imperfectly watched j the only other supposition being that they
occurred accidentally.

Our knowledge of the etiology of the diseases which affect the
human body is as yet, unfortunately, very limited ; indeed, there are
but few maladies of which we have succeeded in determining the
real cause. When, however, no plausible explanation can be found,
medical men, as well as unprofessional persons, are apt to at-
tribute disease to agencies which are quite imaginary ; as, for
example, to ^' catching cold,^'' " errors of diet/' or even " mental
emotions;" and thus the suppression of eruptions, or of the per-
spiration of the feet, has been recognised as one of the causes of
various affections. An unprejudiced observer, however, wiU not be
led to believe in such a theory. My experience, at any rate, teaches
me that persons may suffer for years from one of the local forms of
hyperidrosis (particularly that form which affects the feet), and yet

HYPERIDROSIS LOCALIS. 87

find this complaint no talisman, capable of protecting them from
intercurrent internal diseases ; and, conversely, although I have often
succeeded in putting a stop to the profuse sweating, I have never,
during more than twenty years, seen any other malady arise as
a result of the cure of this complaint.

I am, at present, unable to explain the exact cause of the hyperi-
drosis which aifects the hands and feet, or, indeed, of any one of the
forms of this disease. I find, from statistics, that it affects the
young as well as the old, both males and females, rich and poor,
those who are of cleanly habits and those who are dirty, persons who
are in good health and those who suffer from other maladies.

Since, then, our acquaintance with the causes of these affections
is so scanty, we can follow an empirical method only in our efforts to
cure them. Fortunately, however, these efforts are attended with
success.

Although, from a theoretical point of view, it appears very probable
that we might be able, by energetic stimulation of the kidneys, to
diminish the amount of fluid excreted by the action of the skin, yet
experiments actually made with this object have led to no satis-
factory results. Neither diuretics nor purgatives, whether mild or
drastic, have, even when continued for a considerable time, effected
a cure of the hyperidrosis. :

Many authors have advised the use of other internal remedies,
besides those already spoken of, iu the treatment of this complaint.
Thus, Paulus ^Egineta recommends astringents ; Van Swieten, salvia ;
Sydenham, Malaga wine. Dupont^ asserts that he cured a woman
who had suffered for six years, from chronic sweating by the admi-
nistration of the extract of aconite (in a dose varying from gr. ss
to gr. xvj (!), daily). Rayer advises the employment of the Agaric
blanc^ and of cinchona. Among other remedies, proposed by dif-
ferent writers, may also be mentioned whey prepared with alum,
camphor, the Elixir viirioU MinsicJiii,^ opium, &c.

The " antiphlogistic" method of treatment, including venesection
and the application of different counter-irritants, has also been
employed in the attempt to control these forms of sweating.

^ "Hist, d'une sueur chronique," &c. (' Jouru. Gen. de Med.,' 1807, t. xxx,

P- 33)-

' The Fohjporus officinalis (Micbaux), a fungus whicli grows on the trunk of

the larch.— [Ed.]

^ This preparation resembles the " Acidum Sulpburicum Aromaticum" of the

Edinburgh Pharmacopoeia. — [Ed.]

88 AFFECTIONS OF THE SECRETION OF THE SWEAT-GLANDS.

However, no one of these plans has proved successful in the hands of
my predecessors or contemporaries. Hence they have generally en-
deavoured to get out of the difficulty, so far as the patient was
concerned, by asserting that it is not advisable, in these cases, to
suppress the perspiration too suddenly. In reference to this point
we meet with the most extraordinary assertions, every kind of disease
being said to be produced by the sudden checking (no doubt, by
bunglers in their art) of the perspiration of the feet. Thus, Jos.
Frank^ relates that a man, aged thirty, whom he had previously cured
of an attack of hemiplegia, died quite unexpectedly, in consequence
of his skin having been exposed, while sweating, to a cold draught ;
and Rayer asserts that, in a patient under his care, the suppression of
the perspiration of the feet was followed by a chronic pleurisy.

Although I could find many similar instances in the older medical
works, I quote these two only, because they are sufficient to show
what fanciful views were formerly indulged in, and how even
physicians of great skill were influenced by the prejudices of their
age. It is hardly necessary for me to add that all such state-
ments are based on a complete perversion of the facts, and rest on
no scientific foundation whatever, so that, in the present state of
physiology and pathology, they do not even require to be refuted.

The large number of local remedies employed and recommended
by the older physicians with the object of checking the llyperidrosis
pedum shows, however, that, in reality, they did not shrink from
"' suppressing" (or, in other words, curing) this afi'ection ; and also
that the many internal medicines which they prescribed did not suc-
ceed in removing the complaint. Among the substances which they
thus applied locally may be mentioned the sulphate of zinc, alum, the
tincture of kino, tannin, the oleum cadini, and various preparations
of iodine, including its combination with glycerine. Again, they
recommended the use of waters containing carbonic acid, and pre-
scribed sulphur baths, or the use of salt-water baths for the feet ; or
they directed that the skin should be frequently washed with water
or with very dilute alcohol or acetic acid.

But although I have repeatedly had occasion to employ all these
local remedies, I have yet in no instance been able to satisfy myself
that they produce any good effects, while I have succeeded in curing
this affection by the adoption of a diff'erent method of procedure,
"which I will now explain.

' Op. cit., band iii, p. 320.

HYPERIDROSIS LOCALIS. 89

In slight forms of hyperidrosis, such as affect the skin of the
axillae, the genitals, or the palms of the hands, marked benefit has
resulted from the frequent local apphcation of a solution containing
one drachm of tannic acid in six ounces of alcohol. This liquid
should be rubbed into the part several times a day, and the skin
must not be wiped afterwards. A little powdered asbestos is to be
sprinkled "on it while still wet, and with this the part is to be again
rubbed till it is dry.

In cases in which the feet are affected with this complaint, but in
which it is of no great severit}^ all that is necessary is to dust some
pulverulent substance into the socks or stockings. Starch, lyco-
podium^ powdered asbestos, almond br^m (Maudelkleie), or even
common flour, may be used for this purpose. Some writers advise
the addition of a little cream of tartar to these powders, but I
regard this as superfluous.

In intense forms of this affection, however, in which flie secretion
is fetid, this method is not attended with success. A somewhat
more complicated plan of treatment is then required for the cure of
the disease.

It will be remembered that, according to the explanation given
above, the fetor, in these cases, is due, not to any substance existing
in the secretion when first poured out, but to a decomposition which
it is apt to undergo when absorbed by the coverings of the feet, so that
it cannot evaporate. Obviously, therefore, a most important point
in the treatment of this affection is the removal, once for all, of the
stinking socks or stockings, which have often been impregnated with
perspiration for weeks, or even months. "When this has been done,
and when it has been fully ascertained that the simple applications
above described are not sufficient to cure the disease, recourse may
be had to the following procedure, which will invariably be attended
with success.

A certain quantity of the simple diachylon plaister (Emp. Plumbi,
Emp.Lithargyri) is to be melted over a gentle fire, and an equal weight
of linseed oil is then to be incorporated with it, the product being
stirred till a homogeneous mass is produced, sufficiently adhesive not
to crumble readily to pieces. This is then to be spread over a piece
of hnen, measuring about a square foot. The foot of the patient,
having been first well washed and thoroughly dried, is now to be
wrapped in the dressing thus prepared. Pledgets of lint, on which
the same ointment has been spread, are also to be introduced into

90 AFFECTIONS OF THE SECRETION OF THE SWEAT-GLANDS.

the space between each pair of toes, to prevent their touching one
another ; and care must be taken that the foot is completely covered,
and that the dressing is accurately in contact with the skin. When
this has been done an ordinary sock or locking may be put on the
foot, and outside this a new shoe, which must be light and should not
cover the dorsum of the foot. After twelve hours the dressing is to
be removed ; the foot is then not to be washed, but must' be rubbed
with a dry cloth, or some one of the above-named powders may be
applied to it. The dressing is then to be renewed in the same way as
before, and its application is afterwards to be repeated twice a day.

This procedure must be continued for from eight to twelve days,
according to the severity of the case. During this time, however,
the patient need not keep his room, but may go on with his business
as usual. At the end of this period the dressings and pledgets are
to be removed, the foot is to be again rubbed with some pulverulent
substance, and the patient may then be allowed to wear his ordinary
shoes and stockings.

In the course of a few days it will be found that a brownish-
yellow layer of cuticle, about ^"' thick, is beginning to peel off from
all those parts of the skin which were before affected with the disease,
and that a healthy, clean, white surface of epidermis is exposed as
this substance separates.

TVhen this layer of cuticle has become completely detached the
foot may for the first time be washed, but it will still for some time
be advisable to dust some pulverulent substance into the stocking,
or to rub it into the skin of the foot.

After the lapse of a fortnight or three weeks from the first applica-
tion of the dressing the hyperidrosis will generally have disappeared,
and the cure will last for a year or longer, or may even be perma-
nent. In quite exceptional cases, however, it will be found that a
single course of this treatment is not sufficient to effect the complete
removal of the complaint. The whole procedure must then be gone
through a second time; but this will certainly, and without exception,
bring about a cure.

I have practised this mode of treatment for more than twenty
years and in many hundred cases. In no instance have I seen any ill-
effects arise, whether immediately after the application of the dressing
or in the course of several years, during which the patients have been
under observation. This I say for the satisfaction of those who might
fear to adopt this plan.

ANIDROSIS. 91

B. Anidrosis.

As in the case of hyperidrosis, I shall confine my remarks upon
anidrosis to those forms of it which concern dermatology, the im-
mediate subject of this work.

Now, we'often find that during the course of chronic skin affec-
tions, and as a result of their presence, the secretion of the sudori-
parous glands becomes much diminished, if not entirely suppressed,
or, at any rate, that no sweat is formed except on those parts of the
cutaneous surface which are free from the complaint. Thus, in cases
of ichthyosis the only regions which remain moist and perspiring
are those which are unaffected with this disease, such as, for example,
the axillge, the flexor surfaces of the elbows, the genitals, the hams,
the inguinal regions, the palms of the hands or the soles of the feet.
Even at these parts the secretion is suppressed whenever they also
are attacked with ichthyosis.

The same thing may be observed in those who are affected with
prurigo ; and as either ichthyosis or prurigo, for the most part,
lasts throughout the whole life of the individual, it may be said that
in each of these affections the perspiration is, in general, altogether ab-
sent. In cases of extensive eczema, again, no sweat is formed on any
part of those regions which are the seat of the disease. Hence when this
affection is very widely diffused over the cutaneous surface there may
remain but a very small tract of healthy skin by which this secretion
can be carried on. As, however, eczema after a time undergoes spon-
taneous involution or, at any rate, may be cured by appropriate treat-
ment, wehave in this instance an opportunity of observing an alternation
between the cutaneous disease and the performance of the perspiratory
functions. When the eczema begins to get well the cutaneous
glands gradually resume their normal activity, and the healthy moist
condition of the cutis returns, whereas the skin was dry to the touch,
and poured forth no secretion, so long as it was affected with the disease.

It must not be supposed that the real explanation of these facts is
different from that which I have given, and that the eczema appears
because the sweat is suppressed, instead of the skin ceasing to per-
spire because it is already in a diseased condition.

The same thing is seen likewise in cases of psoriasis and of hchen
ruber, and as these affections also are curable the relation between

92 AFFECTIONS OF THE SECRETION OF THE SWEAT-GLANDS.

them and the suppression of the perspiration will naturally be the
same as in the case of eczema.

The cm-e of the anidrosis will, of course, coincide with that of the
chronic cutaneous affection which gave rise to it.

(2) Qualitative Changes in the Secretion of the Sudoriparous

Glands.

I have already expressly stated, in the beginning of this chapter,
that an exact chemical analysis of the sweat, or, indeed, of any one
of the cutaneous secretions, is *as yet a desideratum. It is, therefore,
obvious that, in quoting the accounts given in different works of
the affections wliich come under this head, I am playing the part of
a medical historian rather than of a pathologist.

I have, in fact, never been able to satisfy myself that the sweat
(that is, the secretion of the sudoriparous glands alone, without ad-
mixture of sebaceous matter) ever contains any foreign substances
excreted with it by the skin. Certain \vriters, however, among
whom are Fuchs, Erasmus Wilson, and Mason Good, say that
they have detected several such matters in the perspiration, namely,
in some cases blood or milk ; in others a colouring matter, or a
substance containing an odorous principle. IVow, of course, I can-
not assert the falsity of these statements, and, therefore, I shall con-
tent myself with simply bringing them under the notice of my readers.

Concerning bromidrosis, liowevcr, I have, in the proper place,
already expressed my opinion, and I have here only to mention,
further, that several authors have described cases in which the
perspiration, without any discoverable cause, has given off odours of
a perfectly specific kind. Thus, this secretion is said to have possessed
in different instances the smeU of vinegar, butyric acid, musk (Rayer,
Speranza), and sulphur (Schmidt). Other writers, again, have as-
sociated certain odours with particular diseases, asserting that in
scabies the perspiration has a mouldy, in syphilis a sweet, in gout a
sour, smell. Lastly, in " putrid ^^ and scorbutic affections a
putrid smell has been ascribed to the cutaneous secretion, and it has
been asserted that in jaundice the smell is like that of musk, in
scrofulosis like that of sour beer,^ and in intermittent fever like that

' Stark, ' General Pathology.'

HiEMATIDROSIS. 93

of newly-baked bread. Anselmino found free acetic acid in the
perspiration of a woman recently confined. According to Stark
(whom I have quoted above) the amount of free lactic acid is in-
creased in scrofulosis, rickets, and certain " skin diseases." Ansel-
mino, again, detected ammonia in excess in the perspiration of gouty
subjects, and Behrend observed the same thing in typhus and ia
putrid fevers.

Chromidrosis.

No instance of this affection having come under my own observa-
tion, I can only quote the descriptions of it given by other writers.
Thus Eayer states that cases occur in which the sweat is of
different colours — green, black, blue, or yellow — but he confesses
that he has himself seen none of these varieties. Fuchs says that
cases have been observed in which, sometimes over the whole body,
sometimes at particular spots, the cutaneous secretion has been yel-
low, green, blue, brown, or black. Besides staining the linen, the
perspiration dried on the skin of the persons thus affected into a
coloured powder, which, however, could easily be scraped off, the
healthy skin beneath being then exposed. Erasmus Wilson also
admits that he has seen no instance of this affection.

Hcamatidrosis.

Under this name writers speak of the spontaneous escape of blood
from the " pores" of the skin, that is, either from the sebaceous or
the sudoriparous glands. This is, however, an affection which
is assuredly very rare, though its occurrence may not be physiologi-
cally impossible. Moreover, it ought, in strictness, to be re-
garded not as a Moody ^perspiration, but as a hcBmorrhage from the
skin at certain points, namely, the mouths of the cutaneous glands.

The term hsematidrosis should, I think, be apphed to those cases
only in which all the cutaneous glands (but especially the sudori-
parous), being in a state of exalted activity, should, consequently,
pour out a large quantity of fluid containing blood mixed with
their usual watery secretion. No one, however, so far as I am
aware, has ever seen such an affection as I have been supposing.
The complaint described by writers as hsematidrosis has always
been simply a haemorrhage from the skin. Such cases are, for in-

94 AFFECTIONS OF THE SECRETION OF THE SWEAT-GLANDS.

stance, recorded by A. Finol/ Schilling,^ and Lenhossek.^ Erasmus
Wilson/ again, has seen two instances of this aflFection occurring in
ladies, in one of whom the bleeding spots were placed symmetrically
upon the forehead, chin, and cheeks.

Such cases of spontaneous haemorrhage from some minute points
upon the surface of the skin have also come under my own observation.
In one of them the patient was a lady, in whom the blood flowed from
the caruncula lachrymalis. In another case, also that of a female,
the haemorrhage took place from time to time at the nipple. In
both these instances, however, the bleeding occurred, as will be
noticed, at parts which are very vascular, and covered with a delicate
cuticle, so that some slight injury might possibly have been received
unobserved by the patient. A third and much more remarkable case
was that of a young man, strong and well-nourished, who was
attacked repeatedly by haemorrhage from the surface of the lower
limbs. This generally occurred during the night, so that he first
became aware that the bleeding had taken place by finding the sheets
stained with spots of blood when he awoke. I once, however, saw
blood flow from the uninjured back of the hand of this patient while
he was sitting near me at table. The blood formed a jet, which
would about correspond in size to the duct of a sweat-gland. This
jet had also a somewhat spiral form, and rose about 1'" above the
surface of the skin.

These haemorrhagic affections, therefore, do really occur, but, as
I have stated, are rather uncommon. When, however, we read the
statements of certain writers that many such cases have come under
their observation, we cannot but think that they have been deceived,
and that, in some instances, the haemorrhage was produced artificially.

Thus, we read in certain books, although not, perhaps, in medical
works, of cases in which bleeding has occurred, not only from human
beings, but even from inanimate things. It has probably been seldom
possible to discover the real source of such pretended haemorrhages.
As, however, I was once fortunate enough to see one of these cases

' A. Finol, " Observation d'une d^g^ueration telle que le sang transoudoit
par la peau ;" Sedillot, 'Kec. periodique de la Soc. de Med. de Paris,' 19,

P- 71-

^ T. Ch. Schilling, " De sudore sanguineo post graves convulsivos et spasmo-
dicos affectus erumpente, feliciter tandem sublato," 'Acta Acad. Nat. Cur.,'
vol. iii, p. 425.

^ ' Physiologia Mediciiialis,' vol. iii, p. 352.

* ' On Diseases of the Skin,' London, 1863, p. 615.

HiEMATIDROSlS. 95

sifted to tlie bottom^ I will here give the following authentic history
of the aflFair.

More than ten years ago there lived in a village not far from
Vienna a woman who was said to take neither food nor drink, and
who asserted that every Friday, between the hours of ten a.m. and
noon, haemorrhage occurred spontaneously from her skin at various
points, but especially from her face, feet, and hands. The parts were,
in fact, said to be the same as those from which blood flowed during
the crucifixion of our Lord.

Now^, as this occurrence created a great sensation in the neighbour-
hood, and attracted numerous pilgrims from all parts of the country,
the authorities found themselves compelled to make a thorough
investigation of the matter. Dr. Haller, a physician who held a high
position in the General Hospital at Vienna, was sent to the spot, with
the necessary staff of police, in time to place the woman under sur-
veillance on a Thursday, and to bring her before the Friday to Vienna.
Here she was placed in a room, so that she could be watched
uninterruptedly, night and day, by medical men.

The Friday came, and the woman did not bleed. She, however,
took nothing during that day nor till the evening of the Saturday,
when, tormented by hunger, she asked for food, and ate a con-
siderable quantity. From this time she took nourishment regularly,
and the haemorrhage never recurred.

The case just related is probably similar to not a few others which
are recorded in the history of spontaneous haemorrhages, but which
■were never brought into the clear light of scientific investigation,
so as to be examined without prejudice and — explained.

The names given to the various forms of spontaneous haemorrhage
from the cutaneous surface have generally answered to the causes by
which they w^ere supposed to be produced. Thus, Fuchs^ uses the
terms haematidrosis, and dermathaemorrhois {sudor sanguineus ex hce-
morrhoidibus snppressis) . In another part of his work^ he also speaks
of a haemidrosis menstruahs {sudor cruentus ex catameniis suppressis) .

Both these kinds of haemorrhage, the haemorrhoidal as well as the
uterine, may, in the opinion of this writer, be checked by various in-
jurious influences, such as chills, mental emotions, &c., and he
supposes that, as a result of the suppression of these discharges,
metastasis occurs to the skin, giving rise to a discharge of blood
from its surface.

> Op. cit., p. 503. 2 Op. cit., p. 472.

96 AFFECTIONS OF THE SECRETION OF THE SWEAT-GLANDS.

These causes of haemorrhage from the skin are, indeed, fre-
quently mentioned, not only by Fuchs, but also in many of the older
medical works, and, therefore, I feel myself called upon to point out
how completely incorrect and devoid of all foundation such assertions
are.

I freely confess (and many other physicians will assuredly do the
same) that I am not acquainted with any artificial means of " sup-
pressing" haemorrhage (whether hseraorrhoidal or menstrual), nor,
on the other hand, with the distinctions between such a " suppres-
sion^' and a cure. Surely no one will maintain that it is a natural thing
for any one to lose blood continually from the rectum, or even from
the uterus. If this were the case medical and surgical writers could
not with consistency discuss the various remedies by which these
haemorrhages may, in general, be stopped. I am, then, of opinion
that we may, without any fear of causing metastasis to the skin,
combat each of these complaints by the appropriate mode of treat-
ment, and that bleeding from the haemorrhoidal veins should be
checked in all cases, and haemorrhage from the uterus whenever its
quantity is excessive.

Galactidrosis, Galactorrkcea erronea, Sudor lacleus (Milclischweiss) .

Under these names there are described, especially in the older
works, certain diseases of lying-in women, said to be caused by
a metastasis of the milk, sometimes to one of the internal organs,
sometimes to the skin.

So long as the puerperal diseases of the uterus, ovaries, &c., were
not known, all maladies arising after childbirth were referred to a
" metastasis" of the milk. In the last century Van Swieten, Levret,
Seile, and others, gave minute descriptions of aJSections of various
organs supposed to be produced by " retrocession" of this secretion.
But now that pathological anatomists are famihar with the morbid
changes which occur in the puerperal state, and that chemistry and
the microscope liave made clear the composition of the milk, no one
any longer fancies that this secretion is liable to " metastasis," and
that he sees it exuding from the swollen axillary glands of a woman
recently confined (Siebold), or from her nose after violent sneezing
(Fleischmann) } Puerperal affections are at the present day regarded

- ' Hufelaud's Journal,' 1836, Part vi.

URIDROSIS. 97

as patliological processes arising from a special cause, but not as dif-
fering ill any essential respect from inflammatory and suppurative
diseases produced by other conditions.

As a further proof that there is no such thing as a metastasis of
the milk to the skin I may state that no one of the many phy-
sicians Avho have attended in the lying-in hospital of Yienna (in
which there are, on an average, 8000 births annually) has ever seen
milk exude from the skin, although epidemics of puerperal fever have
carried off many victims. Nor, again, have any of the physicians
engaged in our school of pathological anatomy (who find material
for their world-renowned labours in tliousands of post-mortem exami-
nations) ever found occasion to demonstrate a metastasis of the milk
in the dead body. I think, therefore, that I am justified in expressing
the doubt whether any diseases have ever arisen from this cause, and
in regarding galactidrosis as an affection altogether mythical.

Uridrosis [Sudor iirinosiis, Harnschweiss) .

This name is given to an affection in which, while the renal secre-
tion is defective, the perspiration possesses a urinous smell. This
character may either belong to the sweat generally or only to that
which is formed at certain parts of the cutaneous surface.

The older writers, Salmuth,^ Haesbart,- Marc. Donatus, Sauvages,
Arnold,^ and others, record cases in which, the urine being de-
ficient in consequence of disease of the kidneys, the skin took up
the function of these organs and became covered with an abundant
urinous perspiration.

Even by the thorough investigations of the chemists and physio-
logists Lehmann,'* Schottin,^ Schlossberger, Liebig, Scherer, and
Wöhler, it has not yet been proved to demonstration whether or no
urea exists, as such, in the blood. Most writers are, however, of
opinion that this is the case, and that the kidneys are merely excre-
tors of this substance. Urea has, indeed, been often shown to be
present in the circulating fluid ; and tlie fact that attempts to detect
it have sometimes failed by no means justifies the conclusion that this

' Cent, ii, oLserv. 82.

^ 'Ephemer. iKit. cur.,' Dec. ii-, A. x, obs. 73.

^ 'London Med. Repository,' 1828, April.

■* 'Lehrbuch der phjsiolog. Clieniie,' Band i, 1850, pp. 165 et seq.

'•" 'De Sudore,' diss, inaug., &c., Lipsia;, 1841.

98 AFFECTIONS OF THE SECRETION OF THE SWEAT GLANDS.

substance is formed elsewhere, and not in the blood, from the decom-
position of nitrogeuized substances.

Such being the case, it is anything but unreasonable to suppose
that when the secretion of urine by the kidneys is interfered with
the different solid tissues will be traversed by blood overloaded with
urea, and, therefore, that this substance will be present in the sweat,
as well as in the other fluids.

Those who have made direct experiments in reference to this point
have, however, very rarely succeeded in detecting urea in the perspi-
ration, and certain chemists, among whom is Lehmann,^ even main-
tain that this has never yet been done. But the investigations of
Schottin,^ Dräsche,^ Treitz,* Hirschsprung,^ and others, have furnished
positive proofs that, under certain conditions, urea may be discovered
in the cutaneous secretion. I may quote, especially, the observa-
tions made during the year 1 855, when the cholera was raging in
Vienna, by Dräsche. In certain severe cases of that disease this
physician observed, on the surface of the scalp and face, a scaly
deposit, resembling fine white meal. On examining this substance
he found it to contain crystals of oxalate of urea, of which the
nature was determined both by their form and by their chemical
reactions.

It must be admitted, however, that such an alteration of the
cutaneous secretion is exceedingly rare ; and it has still to be showii
which of the glands of the skin were concerned in the excretion of
the urea. The crystals were, liowever, found by Dräsche at those
parts where the sebaceous glands are most abundant and of the
largest size, and their presence was associated with the formation of
sebum in excessive quantity. These facts are, of course, rather in
favour of the supposition that the urea was, in these cases, excreted
not by the sudoriparous, but by the sebaceous glands.

^ Op. cit., Band ii, p. 382.

^ 'Archiv f. pliys. Heilkunde,' 1851, 1853.

^ ' Wiener Mod. Wochenschrift;,' 1856.

* 'Prager A''ierteljahrsschriffc,' 1859.

^ 'Wien. Med. Wochenschrift,' 1865, No. gg.

CHAPTER YI.

CLASS 111 (couimued). —Al^OUALlM SECRETIONIS GLANDULARUM
CUTANEARUM.

C. — Affections caused by Moubid States of the Secretion,

on BY changes in THE STRUCTURE OF THE SeBACEOUS

Glands.

The diseases now to be described are of two kinds : on the one
hand, the functional activity of the sebaceous glands may be per-
verted ; on the other hand, these organs are subject to certain
morphological changes, due, for the most part, to a retention of
their secretion.

Again, the alterations in the functional activity of the sebaceous
glands may themselves be further subdivided. In some cases an
excessive amount of sebum is produced, in others its quantity is
unduly small. I shall, in the first place, describe those complaints
which come under the first head, reserving for future description
those which belonor to the second.

I. Cutaneous Affections caused hy the secretion of Sebum in
excessive quantity.

As is well known, the sebaceous glands are directly connected
with the hair-sacs, of which, indeed, they may even be said to form
a part ; and the sebaceous secretion is discharged upon the cutaneous
surface through apertures common to both these structures.

Now, the effects of an excessive formation of sebum vary widely
in different forms of the diseases to which it gives rise. In some
of them the ducts remain open, and there is no obstacle to the
escape of the secretion, as fast as it is formed ; but in other cases
its excretion is prevented, so that it accumulates within the ducts^

100 AFFECTIONS OF THE SEBACEOUS SECRETION.

and ultimately within the glands themselves ; and this result may ^
be produced either by the plugging-up, from some cause^ of the
mouths of the ducts^ or by a loss of the contractile power (Con-
tractionsfahigkeit, peristaltische Bewegung) of the secreting organs.

Mr. Erasmus Wilson^ has, indeed, made use of the expressions " ex-
cretory aperture remaining open^' "excretory aperture being closed," to
indicate the important differences to which I have referred. But this
distinction is not sufficient; for, as I have just stated, the sebum
may be retained, even though the canal be patent, in consequence of
the gland having lost the power of expelling its secretion ; and, on
the other hand, the duct may be closed Avithout any accumula-
tion of sebum taking place, if, at the same time, the gland should
cease to secrete.

For these reasons, therefore, I divide the diseases now to be
described into those in which there is no impediment to the excretion
of the sebum and those in which the excretion of this substance is
prevented.

(i) Affections in which the Sebum is secreted in excessive qiiantity,
there being no impediment to its excretion.

The cutaneous diseases which come under this head are now
pretty uniformly described by all dermatologists, but under various
names, such as seborrhoca, seborrhagia, stearrhoca, steatorrhoca,
steatorrhagia. Cutis unctuosa, Eluxus sebaceus. Yarns sebaceus. Acne
sebacea. Ichthyosis scbacca, Schmccrfluss, kc. Of these terms,
seborrhea is the one which I shall employ in this work.

Seborrhma.

History. — In the writings of Hippocrates,- Galen,^ Celsus,'^
Priscianus,^ Actuarius,*^ and Trallianus,? mention is made of the
occurrence of defluvimn cainllorum, which is one of the symptoms
constantly present in the form of seborrhoea affecting the scalp.
Again, the Greeks designated by the name of Trirvplatrig a cutaneous
affection occurring on the head as well as on other parts of the
body, and characterised by the formation of scales; while Celsus,

1 The 'Student's Book of Cutaneous Medicine,' &c.j.8vo, Lond., 1865.

^ Aplior. xi, xii. ^ Lib. i, ' Dc Comp. Med.,' sec. loo.

•• Lib. vi, cap. i. ^ Xjib. i, ' Medic'

" Lib. ii, ' Method.' ' Lib. i, cap. 2 ct 4.

SEBORRHCEA. 101

Paulus ^Eginetaj and the Arabian writers, applied tlic term Porr'ujo
to a similar complaint- But we do not find, either in the works of
these authors nor in those of the surgeons and dermatologists of a
later period (such as Guy de Chauliac, Ambroise Pare, Mercurialis, and
Lorry), any accurate description of those diseases which give rise to
an excessive formation of scales and a falling off of the hair, and
which we now recognise under the name of seborrlicea.

Plenck/ indeed, writes as follows : — " Porrigo farinosa sen spuria
est congeries materia nng^iinosa imlverulenta .... qua crustam
sordidam atqiie faitidam siih pectin e farina crassa forma delahentem
constituit. Materi.es Jiac farinosa vel firfaracea humor sehaceus
glandidarum capitis esse videtur." But this short and aphoristic
definition was not sufficient to explain the essential nature of the
affection to his contemporaries. They, for the most part, coincided
in the view taken by Willan and Bateman,^ who placed this com-
plaint among the squamous diseases of the skin, and adopted for it
the Greek word Pityriasis.

Alibert, however, employed, instead of this name, that of Tinea or
Porrigo, and described two distinct forms of this affection, the T.
sen P. furfuracea, and the T. seu P. amiantacea. The second of
these diseases was first mentioned by Alibert; but it is easy to
recognise that both it and the T. furfuracea are mere varieties of a
Seborrhoea capillitii, and this is the case also with the Teigne
amiantacee and the T. furfuracee of Mahon,'^ to which Alibert
also refers.

On the other hand, Biett* (who was a follower of Willan in the
use of the term pityriasis, and who described a pityriasis of the eye-
brows and of the chin, as well as of the scalp) was the first to men-
tion the occurrence of a seborrhoea on parts of the body uncovered
with hair, and he gave to this affection the name of maladie fol-
liculeiise, on acne sebacee.

In the first edition of his work Kayer^ described, under the title
of " secretions morbides des follicules sebaces," several diseases due

1 'Doctrin. de Morb. Cutaneis,' 1783, p. 86.

^ ' Delineatious of Cutaneous Diseases, exliibitiug the appearances of the
principal genera and species in the Classiücatiou of Dr. Willan,' by Dr. Bate-
man, 181 7, plate XV.

^ ' llecherclics sur la Nature des Teignes,' Paris, 1829,

* 'Abrege pratique,' &c., Paris, 1817, 4eme edition, p. 304.

^ 'Traite theorique et pratique des Maladies de la Peau,' Paris, 1827, tome ii,
p. 246.

102 AFFECTIONS OF THE SEBACEOUS SECRETION.

to morbid conditions of the sebaceous glands, and their secretion ;
but in the second edition^ he applies the term finx sebace to those
affections in which the sebum is secreted in excessive quantity.

Trom the cases recorded in detail by Rayer (and especially from
those numbered 191, 193, in the first edition, and 182, 183, in the
second), it is evident that he had observed the most varied forms of
seborrhcEa affecting the scalp and face. I must not omit to men-
tion, also, that this writer attributed to a fuxiis sebaceus two cases
of which Bateman had given a drawing, in Plate 28 of his ' Atlas,"
and which he and Dr. Thomson had regarded as instances of an
Ichthyosis faciei.

In the most recent books on dermatology (such as those of
Eiecke, Fuchs, Simon, Gibert, Cazenave, Chausit, Duchesne-Duparc,
Devergie, Erasmus Wilson, Thomson and Parkes, and Tilbury Pox)
the disease with which we are now concerned has been very gene-
rally distinguished from pityriasis, and described more or less
minutely under the different names I have abeady cited. But it is,
at the same time, evident, from numerous passages in their works,
that many of these writers were fully aware of the difficulty which
often exists in drawing the line of separation between seborrJicea
and pifj/riasis.

On carefully examining the mode of development of seborrhoea
on different parts of the cutaneous surface, we find that the appear-
ances to which this complaint gives rise vary greatly with differences
in its intensity and situation, as well as with the individual pecu-
liarities presented by the patients affected by it. Indeed, a study
of the varieties thus produced enables us to show that some of the
diseases usually described under the names of pityriasis or ichthyo-
sis ought, in reality, to be regarded as forms of seborrhcea.

In support of this opinion, I may refer to the anatomical views
which have been so ably taught by Yirchow,^ " The hair-sacs,"
says this writer, " are well known to be involutions (Einstülpungen)
of the skin ; their surface is covered with a continuation of the
cuticle ; and the hairs which grow from their base may be con-
sidered as prolongations of this structure. Thus, the secretion of
the surface is, even here, epidermis. In the interval'" (between the
hair and the cells which line the hair-sac) " is found, in greater or

1 1S35, tome iii, p. 699 {vide 1026 of Dr. Willis's translation).
' ' Die krankhaften Geschwülste : Drcissig Vorlesungen' &c., Berlin, 1863,
Band i, s. 216.

SEBORRHCEA. 103

less quantity, a fatty or greasy substance, formed by tlie sebaceous
glands, the ducts of which open into the cavity containing the hair.
This fatty matter may be either free or enclosed in cells; its
amount, as might be expected, varies greatly, according to the
degree of irritation to which the skin is exposed, and also in pro-
portion to the number and size of the glands at the part, and the
extent to which their secretion may happen to accumulate. In some
cases there is scarcely any trace of this fatty substance, and the
epidermoidal character certainly preponderates in the majority of
these diseases."

The description given by Kölliker of the sebaceous glands and
their secretion also shows that no satisfactory distinction between
this product and the epidermis can be drawn, either during its
formation or dui-ing its passage along the glandular canals. " The
sebum," says Kölliker,^ ''is a secretion which consists, not, like many
others, of a watery fluid containing formed elements, but, so to speak,
of formed elements alone. In fact, it is either made up entirely of
cells loaded with fat, or includes, besides such cells, an admixture of
free oil-globules."

'' The elements of this secretion are formed within the vesicular
extremities of the glands, as the result of a process of cell-develop-
ment and cell-metamorphosis, which we must suppose to take place
in the following manner : — At the bottom of the caecal terminations
of the glands cells are always being generated. These cells are at
first pale, and contain but few granules ; but as they gradually be-
come pushed towards the interior of the glandular vesicles by the
growth of fresh cells beneath them, they very soon acquire an in-
creased number of moderately large, round, dark, fat-granules, with
which they at last become completely filled. In this way the cells
advance towards the excretory ducts ; but, before they can be pro-
perly said to constitute sebum, they have to undergo further changes.
On the one hand, the scattered fat-granules, which they contain,
coalesce so as to form a few globules only, or even a single drop ;
on the other hand, the cell-membranes, which at first (like those of
the epithelium of the glandular passages) were readily dissolved by
alkalies, become more resisting, and, at lengtli; resemble in their
chemical properties the plates of the horny strata of the epidermis."

1 'Mikroskopische Anatomie/ Leipzig, 1850, Band ii, ite Hälfte, p. 188
{vide p. 226 of the first volume of the translation for the Sydenham Society,
by Busk and Huxley).

104 AFFECTIONS OF THE SEBACEOUS SECRETION.

" Now, if this description is correct, the process by wliicli sebuin
is formed reminds one, in many respects, of that which is concerned
in the growth of the cuticle. Thus, the young, easily soluble cells,
at the bottom of the glandular follicles, may be compared to those
of the ]\lalpighian layer of the epidermis, while those less soluble,
filled witli fat and found in the secretion itself, correspond to the cells
of its horny stratum. Two other points may also be urged in
favour of this view. One is the fact that the deep layer of the epi-
dermis which lines the hair-sac is continued into the ducts of the
glands and even as far as the outermost cells of their terminal folli-
cles ; the other is the circumstance that the epidermis itself is, in
some situations, constantly being detached and forming secretions
(I refer to the smegma praput'd penis et clUoridis), which, to all

appearance, are chemically allied to the sebum These

facts," continues Kolliker, "show that there is some reason for
comparing the cells of the sebaceous secretion with those of the
liorny stratum of the cuticle, and likening the process by which the
sebum is formed to the growth of the epidermis; and a further
argument in favour of the same view might be derived from the
way in which these tissues are developed."

Now these conclusions, derived from anatomical and physio-
logical investigations, are supported by the results of clinical obser-
vation, and, therefore, the following appears to me to be the only
admissible definition of seborrhoea.

SehorrJiaa consists m a morhid secretion of epidermis, wJiich is
impregnated with sebum, and cither forms a greasy coating or accu-
mulates in scale-like masses upon a part of the shin which is, in
other respects, healthy.

Before passing on to describe in detail the appearances produced
by this cutaneous affection, I must, in the first place, point out that
it occurs in two distinct forms, of which I term one the S. oleosa
seu adiposa (Acne sebacee fluente of Cazenave) ; and the other, the
8. sicca seu squamosa (Acne sebacee seche of Cazenave) .

Different as are the symptoms of these two varieties, there is yet
no difficulty in proving that they are but modifications of one and
the same disease. For we frequently observe all or, at any rate,
many of the characters belonging to each of them in the same
patient. Again, a S. oleosa may often be noticed to pass into a
S. sicca; and, lastly, on subjecting the morbid products which
appear in these two affections to a microscopical and chemical inves-

SEBORllIICEA OLEOSA. 105

tigation these products are found to consist, in each instance, of
exactly the same elements^ namely, of epidermic cells saturated with
fat-globules. This is the case whatever the seat of the disease,
whether it takes the form of a S. capillitii or a S. prceputii, or of
the so-called pitijnasis furfuracea, s. amiantacea, or even of a
(li^Vised j)itj/riasis tabescentium covering a large part of the cutaneous
surface.

Botli the S. oleosa and the S. sicca attack, in some instances, only
those parts of the head which are covered with hair, while, in other
cases, they occupy the face or some other region richly supplied with
glands, but having no hair ; or, lastly, involve the whole surface of
the body. These variations in the seat of the affection are attended
with certain differences in its characters, and, therefore, I have to
speak of a S. nniversalis and a S. localis, and to divide this last
again into a S. capillitii, 8, faciei, &c.

(i) SehorrJiaa oleosa sen acViposa.
[a) On parts of the body not covered with hair.

When affecting these regions, the S. oleosa consists in the forma-
tion of a shining greasy layer, which covers the skin and gives it
just the same appearance as if it had been smeared over with some
ointment. The oily material may be easily removed by rubbing the
part with a fine dry cloth or with a piece of blotting-paper, wdiich
then presents an unmistakeably greasy stain.

This form of seborrhoea is observed most commonly in young sub-
jects, in whom it occurs on the surface of the forehead, nose, and
cheeks.

In these cases, when the skin is carefully examined, the openings
of the sebaceous glands may be clearly seen to present minute oily
points, and some of the ducts are often found to be filled wdth large
plugs of sebum. It is therefore clear that this secretion is being
formed in excessive quantity.

I may also mention another circumstance observed in patients
affected with the 8. oleosa. This is that, unless the greatest care be
taken to keep it clean, the face of these persons is always dirty, and
is apt to be discoloured by any substance with which they are
much brought into contact by their occupation. We all know that
solid particles, floating in the air, are absorbed more readily and

106 AFFECTIONS OF THE SEBACEOUS SECRETION.

retained more obstinately by a greasy spot upon any article of dress
than by other parts of it, and we can understand that in the same
way the skin of the face, when always covered with an oily layer,
will attract the dust or dirt, and assume an unusual colour. This
is often observed in factories where a great deal of coal is used. Of
the men employed in such an establishment some few are generally
found to be much blacker and dirtier than others, and these
workmen are obliged to wash the face with soap and to rub it hard
in order to get rid of the particles of coal-dust which adhere to it,
while their comrades have merely to use a dry cloth in order to clean
themselves sufficiently.

When it has been of long duration, the S. oleosa, however, gives
rise to appearances which differ from those hitherto described.
Under these circumstances crustts lamellosa, which may be either
as thin as paper or as much as half a line in thickness, form on the
forehead, cheeks, and nose, and even on other parts of the face.
Similar masses also collect on the surface of the genital organs, con-
stituting the smegma prcpjmtii et ciiioridis; and, lastly, a deposit of the
same kind, which is then termed the vernix caseosa, is found on the
skin of newly born infants. These masses of sebum may present
various colours ; thus, they may be pale yellow (S. flavescens, Wilson),
brownish-yellow, gray, grayish-green, or even black (S. nigricans).
Their upper surface is uneven and rough ; their under surface, which
is in contact with an otherwise healthy skin, has projecting from it
certain small conical processes which pass into the dilated ducts of
sebaceous glands. These prolongations can, of course, be seen only
Avhen the crusta lamellosa is detached from the skin slowly and with
care.

Tliis form of seborrhoea has received different names, according to
the colour of the crustse lamellosse. Cazenave described and figured
it under the title of Acne sebacce ; Eayer, under that of Icldhjosls
seiacea ; Bateman, under that of Ichthjosis faciei. Again, the
case of Melasma palpehranim reported by Neligan ought probably
to be regarded as an instance of seiorrhoea, the black colour being
due either to dirt or to the accidental presence of dark coloured
pigment in the epidermic cells, cast off as a result of the seborrhoea.
The fact that the black scales, which were repeatedly formed,
could in this case be removed Avithout any injury to the skin
beneath, by rubbing or even wiping its surface, is in favour of the view
that these scales consisted simply of the secretion of sebaceous glands.

SEBOERHCEA OLEOSA. 107

{I/) Oji parts of the body covered Avith hair.

This form of the S. oleosa may either occur alone or accompany
a simiLar affection of parts which have no hair upon them. It does
not, however, present such well-marked appearances as the variety
last described, for so long as the secretion remains fluid it naturally
sticks to the hairs. Bat in infants, in children or adults who have
very thin hair, and in persons wdio are bald, we have an opportunity
of seeing the cuticle of the scalp covered with an oily coating, as a
result of this disease.

When it affects newly born children this complaint is (as is well
known) termed the S. neonatorum (or, in German, Gneis). Ac-
cording to the length of its duration this variety of seborrhcea gives
rise to different appearances. Thus, it is at first attended with the
formation of thin crusted lamellosa, which are of a yellowish-gray
colour ; but after a time, and particularly if the affection is of a
severe kind, dark green or even black crusts present themselves,
by which the hairs are all matted together.

I may take this opportunity of referring to the opinion of M.
Cazenave,! that the Vllca Polonica is a form of seborrhcea. Now, it
is quite true that when the S. capillitii (Gneis) has existed for a
long time, so that the hairs are matted together in an extreme de-
gree, it may sometimes be supposed to be a Plica Polo?iica, not
only by unprofessional persons, but even by those medical men
who believe in the existence of that disease ; but this by no means
warrants M. Cazenave in formally laying down that ''la plique
ii'est autre chose qi^une hypersecretion de la matiere sebacee, en un
mot, qu'u7ie acne sebacee dit cuir chevelii.^' It is much to be re-
gretted that this writer did not attend to the spirit of the passage
which he himself quotes from Lorry^ — '' Bur^im est de eis scri-
bendum habere, quce ipse non videris" Had he done so, he would not
have fallen into the error committed by so many of his countrymen,
of making positive statements about a disease of which no case had
ever come under his own observation.

For all those physicians who live in Poland, where (both by the
public and by the medical men of the country) the term " Plica "

^ ' Traite des Maladies du cuir chevelu,' Paris, 1850, p. 315.
- ' Tract, de morbis cutaueis/ p. 607, at seq.

108 AFFECTIONS OF THE SEBACEOUS SECRETION.

is still frequently employed as the name of a definite affection ; and
also those who, by their position or place of abode, or in the course
of their travels, have been brought into contact with cases of this
kind ; — all these observers have come to the conclusion that the
disease which they have seen may be due to a variety of causes, and
does not arise simply from an accumulation of sebum. As for myself,
I have learnt, both from my own experience and from the writings of
Beschorner,^ Dietl,^ Wcese,^ and Hamburger,* that several different
conditions, affecting the lower animals as well as man, have been
included under the name of Plica Polonica. Thus, various diseases of
the scalp (such as eczema and favus, and even syphilitic ulcers) have
been supposed to be examples of this complaint ; while in other in-
stances the matted and tangled state of hair naturally long and
abundant has been simply due to neglect, or has been produced by
the patient's rubbing wax or honey into the hair, and braiding false
hair with it. Having myself had occasion to observe many cases of
this kind, I am now quite satisfied that there is no disease w/iic/i
deserves the name of Plica Polonica. Indeed, the fact that this
complaint does not exist has now been fully established by careful
investigations and observations ; and it is much to be hoped that
the profession generally will adopt this conclusion, and no longer
attribute to a special disease cases in which the hair happens to bo
matted together by the causes I have mentioned, and in which the
persistence of this condition is due merely to prejudice, superstition,
and neglect of cleanliness.

(2) Sehorrhoea sicca, S. squamosa.

This affection sometimes consists in the formation of pellicles
(Schwarten) of dried sebum wliicli are of a dirty white or pale
yellow colour, look as if they were made of pap which had
undergone desiccation, and are rather firmly adherent. The sur-
face of the skin beneath them is healthy, or, perhaps, slightly
reddened. Like the crustce lamellosa -which, appear in the S. oleosa,

^ ' Der Weichselzopf, nach statistischen und pliysiologischen Beziehungen,'
Breslau, 1843.

^ ' Wiener Med. Wochenschrift,' 1858, Kos. 4, 5, 6. •''

^ • Rust's Magazin,' 1864.

* ' Güusburg's Zeitschrift,' 1858.

SEBOllRHCEA SICCA. 109

these pellicles have certain small needle-like processes (Couiedones,
Talgprü])fe) connected with their under surface.

The appearances produced by the S. sicca are, however, in other
cases, of a diiferent kind. The dried sebum then takes the form of
branny scales, resting upon a skin healthy in all other respects.
These scales are easily removed by scratching or combing the sur-
face, and they also fall off spontaneously in a pulverulent state.
This variety of the affection has been described by authors under
the name of Tinea, s. Porrit/o, s. Pituriasis furfur acea}

The sehorrkma sicca also presents characters somewhat different,
according as the part affected by it is, or is not, covered with hair.

{a) On parts not covered with hair.

This affection may either be confined to a small part of the cuta-
neous surface or diffused over a large area. It consists in the
formation of a fine mealy powder, partially adherent to the epi-
dermis, M'hich itself generally has a greasy feel, and displays a
fatty lustre.

When a large part of the integument or even (as sometimes
hnppcns) its whole extent is affected in this way, the disease is that
which has been termed the piiijriasis tahescentium, scrofulosorum,
tuherculosorwn. The skin then appears loose and flaccid, owing to
the absorption of the subcutaneous fat, and its surface is con-
stantly covered with a great number of minute scales of epidermis
on the point of being cast off.

(i^) On parts covered with hair.

When this alTection attacks the scalp the same minute, white,
mealy scales are formed as in the variety of seborrhoea just described.
Some of these scales cling to the hairs, while others remain u])on
the surface of the skin ; the scurf thus produced is constantly falling
off, and some of it is detached whenever the hair is combed, so that
the clothes on the neck and shoulders of the patient become covered
by it. Moreover, in these cases there is always more or less deflii-
imim cajnllorum. Indeed, the falling off of the hair is usually the
first thing to attract notice, and is more troublesome to the patient
than the formation of the scurf, which is not always abundant.
' Hebra's 'Atlas für Hautkraukheiteu,' taf. viii, figs, i and 2.

110 AFFECTIONS OF THE SEBACEOUS SECRETION.

General Characters of Seborrhoea.

Bistribution . — Seborrhoea sometimes affects the whole cutaneous
surface, but is more frequently limited to some particular region.

Under the head of general sehorrhcca I may refer to the vernix
caseosa, by which newly born infants are covered. In ordinary cases
this appears as a fatty pellicle, spread over the surface of the skin,
and may be regarded as a deposit from the liquor a?nnn which sur-
rounded the foetus. It gives the cuticle a soft and oily feel, and
may, perhaps, render the passage of the child through the maternal
passages less painful.

It is usual to remove the vernix caseosa at once by washing the
infant with soap and water ; but if this be not done the fatty pelhcle
very soon peels off in scales of greater or less size, and the skin is
then found to present its natural appearance.

In certain rare cases, however, the whole surface of the integu-
ment, within a few hours after birth, becomes as smooth as satin,
and of a dark brownish-red colour, and is, at the same time, tra-
versed by numerous cracks and fissures, which make their appearance
more particularly on the fingers and toes, on the buttocks, and over
the flexures of the joints. These fissures interfere very much with
the child's movements, and give it great pain, as is evident from the
cries which it utters on attempting to move. If, however, lard be
rubbed into the skin an infant affected in this way will generally
become quiet at once, and the surface of the skin will be almost
restored to its natural condition. Indeed, this simple procedure may
be sufficient to remove the disease enth'ely, if of no great intensity.

But in some instances this affection is so severe that it is much
more difficult of cure ; and it then not only causes great pain, but
may even lead to serious consequences by preventing the child from
sleeping, and by interfering with its taking the breast. Under these
circumstances the appearance presented by the skin is very like that
l^roduced by a scald, and it may be also compared to the smooth
shining aspect of the surface of a half-roasted sucking-pig. A good
representation of it is given in one of the plates of my atlas.^

This is the disease which has been described by authors under the

• Heft iii, 1859, taf. ix, fig. c.

DISTRIBUTION OF SEBORRHCEA. Ill

name of Iclitliyosis congenita — a name which I cannot admit to be
suitable for it. In the letter-press accompanying the plate to which
I have just referred I have expressed myself upon this point as
follows :

'' The case of which this plate is a representation answers to the
description of the Iclitliyosis congenita given by Heinhausen,i
Behrend/ and Schabel;^ but it differs from the affection known
under the name of Ichthyosis acquisita, not only in the form and
arrangement of the scales of unhealthy epidermis which are cast off,
but also in the condition of the cutis, which, in the infant, presents
no hypertrophic papilla?, such as are observed in the ichthyosis of
adults.

" Another reason for believing that these diseases are altogether .
distinct is the fact that children affected with the so-called I. con-
genita all die within a few days, whereas grown-up persons suffering
from the /. acqiiisita^ even in a severe form, may retain their usual
health for many years,

" Hence, it appears to me to be desirable either, as proposed
by Dr. Heinhausen, to reserve for the affection of infants the name
of Sciitulatio, s. Incrustatio, or to term it the Ichthyosis sehacea
neonatorum, so as to indicate that in this disease the horny layers of
the cuticle contain a large quantity of sebaceous secretion."

The opinion expressed in the remarks which I have just quoted is
supported by all my subsequent experience, and I therefore regard the
complaint which I am now describing, and of which the plate in my
atlas is an illustration, as a sehorrhcea of newly born children, and
not as a form of ichthyosis.^

A general seborrhcea may likewise occur in adults ; but in them
it gives rise to appearances of a different kind, taking the form
rather of a S. sicca s. sqiiamosa. It is attended with the production
of white branny scales, which form more especially on the chest,
face, and back, but also to a less extent upon the limbs. In these
cases, however, there are, in addition, some of the symptoms of a

^ 'De siiigulari epidevmidis deformitate,' Berolini, 4to, i.

2 ' Tkonograpliisclie Darstellung der iiiclit-sypliilitiscbeu Hautkrankheiten,'
Leipzig, 1839.

' 'Ichthyosis congenita, eine Inauguralabhandluug,' Stuttgart, 1856.

* Mr. Er. Wilson has described cases in which such excessive accumulations
of dried sebaceous secretion occur (whether in adults or infants), under the
names of Ichthyosis sehacea (Sauriderma, I. spuria), I. squamosa, and /. spinosa
(op. cit., fig. 5, plate vi, p. 629).

112 AFFECTIONS OF THE SEBACEOUS SECRETION.

S. oleosa, for the parts of the skin between the scales have the
greasy shining aspect which belongs to that disease.

It is this which has been termed by authors the pitt/nasis iahes-
centium, scrojulosorum, s. tulerculosorum ; but it may, in reality,
occur in the case of any individual previously muscular and well
nourished, Avho has suffered for a considerable time from a \vasting
and debilitating disease. In other words, it is not ])ecuhar to
patients who are tubercular or scrofulous, but is likewise observed in
those who are affected with syphilis, chlorosis, or cancer.

The local variety of seborrhoea of the scalp {S. cajnllltli) occurs
both in infants (as the so-called Gneis) and in adults; in either
case it consists in the formation of yellow, brown, or black cnistce
lamellosa about as thick as paper, by which tlie hairs are matted
together. This form of the afl'ection is, however, most com-
monly observed in children wJio are not properly cared for. In
older persons it more generally appears as the so-called jiitijnasis
cajnll'Uii, giving rise to the production of more or less numerous
white branny scales, which are spontaneously cast off from the
surface of the head, and are also readily detached by combing,
scratching, or rubbing it, so that the patient's clothes are always
covered with a coarse mealy powder.

It is, moreover, indisputable that seborrhcca is a mucli more serious
afTcction in adults than in children, with whom, indeed, it appears
to be a physiological rather than a pathological condition ; whereas
in grown-up persons its presence is generally associated with morbid
symptoms of a dilferent kind, and especially chlorosis.

Seborrhcea of the face is met with less frequently during early
childhood than in youths and adults. It sometimes takes the form
of a S. oleosa, affecting the forehead, nose, cheeks, and chin ; while
in other instances it is attended with the production of whitish-
yellow crustce lamellosa, or grayish-yellow, greenish, or even black
scales (as in the Slearrhcea favescens and the S.nlf/ricans of Wilson^).
Lastly, in some cases it may even lead to the formation of j)el-
licles as much as half a line in thickness. These are of a brownish-
yellow colour, and fissured on the surface. They are sometimes
isolated from one another, sometimes continuous over the whole
of the part affected.

Certain cutaneous diseases, and especially sm,all])ox, are also, in
some cases, followed by the appearance of morbid products of a

' Op. cih, pp. 626, 627.

SEBORRHCEA PR^PÜTII. 113

similar nature to those just described, but corresponding in form
and distribution to the original malady. These may either consist
of small, isolated, scutiform crusts, or cover uninterruptedly large
tracts of the cutaneous surface. They adhere rather firmly to
the skin^ and remain long after the disease which gave rise to
them has come to a termination. Thus, I have seen a patient's face
disfigured by crusts of this kind, which were still closely attached
to the epidermis, as long as six months after recovery from variola.

The genital organs of both sexes are also a frequent seat of sebor-
rhoea. Thus, in the male it affects the glans penis, the sulcus
coronarius, and the inner lamina of the prepuce, on which parts a
whitish, greasy substance (known as the smegma prapnfii penis)
collects in considerable quantity; while in the female the white,
cheesy material accumulates principally in the shallow grooves
between the labia and nymphse, in the vestibulum, and between the
clitoris and its preputial covering.

According to Kölliker,^ the smegma 2^i'(Bpuüi penis et clitoridis is

only in part formed by sebaceous glands, but consists mainly of

epidermic cells and fat-globules, and generally contains but few of

the cells which properly belong to the sebum. In support of this

opinion he urges the fact that a substance of this kind is found on

the clitoris, although that organ possesses no glands ; moreover, he

asserts that, even in the penis, the glands of Tyson are often very few

in number, and that, according to microscopical investigations,

whether these glands, in any particular case, are or are not abundant,

cells resembling those of the epidermis of the glans penis and the

inner lamina of the prepuce form an immensely preponderating part

of the smegma. Por these reasons Kolliker thinks that, even in

the male, the glands of Tyson take only a very subordinate part

in the formation of this material.

Without, however, at all wishing to disparage the results of
microscopical investigations, I yet feel bound to maintain, on the
ground of clinical observation, that the genital organs are liable to
be affected with seborrhoea. For our purposes it is surely sufficient
that anatomy has demonstrated in these regions the presence of
sebaceous glands ; their number is not a matter of any importance ;
and even if the clitoris itself contains none of them they are yet
sufficiently abundant on the inner lamella of its prepuce to secrete,
if diseased, the material by which the organ itself is covered.

' Loc. cit.

Hl AFFECTIONS OF THE SEBACEOUS SECRETION.

Wlieu the smegoia is thus formed in excessive quantity, the
affected parts of the prepuce of the penis or clitoris undergo changes
essentially different from those hitherto described. In the male the
fjlam penis appears reddened and swollen, and the prepuce is cede-
matous ; in the female the clitoris and its prepuce become painful
and enlarged, so that this organ is unusually prominent ; and the
nymphee also are found to be oedematous. Moreover, all the parts
affected become covered with an oily, almost fluid, material, which
is often secreted so abundantly that it escapes drop by drop. Thus,
in men who have also a congenital phimosis, this affection may
resemble, and even sometimes be mistaken for, gonorrhoea; and
hence arose the German name (Eicheltripper) for this disease, which
has received the scientific appellation of Balanitis penis seu clitoriclis.
Indeed, an inflammation of the surface of the part, and its pre-
putial covering, is evidently present in these cases.

In -women, again, the discharge may be so abundant as to sug-
gest, at first sight, the presence of a blenorrhcea vagincB. It is
necessary to bear in mind that little girls, as well as grown-up
women, are liable to suffer from this modification of seborrhoea.

That the apparently dissimilar affections of which I have been
speaking have really a common origin, and are due to seborrhoea,
may, to some extent, be inferred from clinical observation, which
certainly shows that the more common, chronic form of disease
frequently passes into the acute, and vice versa.

Seborrhcea congestiva. — I may take this opportunity of referring to
the complaint which I have elsewhere^ described under this name.

This affection first came under my observation in my clmique
where certain patients presented themselves who, although in other
respects healthy, had sharply defined patches of a deep red colour on
the face, especially on the cheeks, nose, and chin. The ducts
of the sebaceous glands which occupied the skin of the diseased
parts were noticed to be obstructed by masses of their secretion ;
and some of the patches were often covered with plates of sebum
already excreted. Hence it occurred to me that this morbid con-
dition was probably the result of a seborrhoea, differing from the
ordinary forms of that complaint only in the extremely congested
and hypersemic state of the integument of the regions affected by it,

' ' Zeii-sclirift der k. k. Gesellschaft der Aerzte,' Baud i, 1845, P- 4°-
Canslatt's ' Jaliresbericbt über die Leistungen der Dermatologie im Jalire
1845,' p. 226.

LUPUS ERYTHEMATOSUS. 115

111 uo work; at that time published, could I find any account of
this complaint, of which the symptoms appeared to me so remark-
able and distinctive as to merit a special description ; and thus I
was led to propose for it the title of selorrJioea coyujediva.

Six years later, in 1851, M. Cazenave^ wrote a paper on a disease
which was called by him the Ltqms erythemaioms, and which I
found to be that previously described by myself under the name
which I have just mentioned.

Since that time I have had repeated opportunities of examining
cases of this disease, and have been able to keep several of them
under observation during a long period. And I have been induced
to adopt M. Cazenave's name for it in preference to that which I
had myself originally chosen. For this complaint, in most in-
stances, takes a chronic course, lasting generally for many years,
and when it disappears cicatrices are formed. Now, these characters
certainly correspond to those of lupus rather than to those of
seborrhoea.

Nevertheless, I am able to show that, in this affection, there is
really a peculiar degenerative change, not only in the sebum itself,
but also in the organs by which it is secreted. Indeed, this is, in
some cases, indicated by the fact that the sebaceous glands seated
on the reddened and diseased surface are plugged up with masses
of secretion resembling that which constitutes comedones, but of
an unusually firm consistence.

Dr. I. Neumann also, who has examined the skin of the cheeks
of individuals affected with this disease, has pointed out that its
seat is in the sebaceous glands.

In the letterpress which accompanies my Atlas ^ I have given the
following description of the hijius erytkematoms. "The first indi-
cation of this disease consists in the formation of sharply-defined
patches, very little raised above the cutaneous surface, but rough
to the touch and of a grayish-red colour. In many cases we
afterwards find these spots covered with small hard points of a dark
green colour, which consist of sebum plugging up the mouths of the
glands. These " comedones '* may be either quite separate from
one another, or packed side by side, or even fused into a single mass.
In other instances, however, there appear on the reddened patches
thin white pellicles, which present on their under surface numerous

• 'Annales des Maladies de la Peau, et de la Syphilis,' vol. iii, No. 11, 185t.
- ' Erste Lieferung,' 1856, tab. 6 und 8, s. 4.

116 AFFECTIONS OF THE SEBACEOUS SECRETION.

thread-like processes passing into the dilated ducts of the sebaceous
glands. These processes^ like the pellicles themselves, consist of
dried sebum mixed with scales of epidermis.

Of the two plates of this disease which form part of J my Atlas
I would particularly draw attention to the second (Tab. 8). This
shows clearly the greenish-red hue of the skin of the face, covered
with numerous dark-coloured comedones. I cannot but believe
that those wlio refer to this drawing will come to the conclusion
that the " liqms enjtJiematosiis " of j\L Cazenave is, in reality, due to
a special change in the sebaceous glands and the secretion formed
by them.

Miologij. — The causes of the affections which I have been
describing have not as yet been fully ascertained. I do not, how-
ever, wish to imitate the course taken by most dermatologists, who
pass over this cpiestion entirely ; and therefore I will here state
all that I have been able to gather from my observation of these
complaints.

In the first place, some of them, which affect almost everybody,
and do not in any way impair the health, are clearly of a physiological,
rather than a pathological, nature. Thus, the Tcrn'ix caseosa of
newly-born infants, and the smegma 2')y^2^iitn penis et cUiondis, are
to be regarded as normal products, unless they are formed in ex-
cessive quantity; and the seborrhoea neonatorum (Gneis) is like-
wise scarcely to be looked upon as a pathological condition. If it
goes beyond a certain point, however, any one of these may give rise
to affections of various kinds, so that there is, in this instance (as in
so many others), a close connection between the healthy state and
that which we consider to be disease. In otlier words, only an
arbitrary line of separation can be drawn between the physiological
and the pathological forms of seborrhcea.

These affections, however, acquire, in certain cases, a peculiar
degree of intensity, and are accompanied by certain morbid states of
the general health, with wliich they undeniably stand in a causal rela-
tion ; for, when these subside, they too disappear. So far, then, as
their etiology is concerned, we are fully justified in laying particular
stress on those forms of seborrhoea which are demonstrably con-
nected with other diseases.

Now, this is especially the case with that local variety of seborrhoea
which occurs on the head and face of young persons and adults,
appearing sometimes as a 8. oleosa, sometimes as a S. sicca, and

ETIOLOGY OF SEBORRIICEA. 117

generally attended with a more or less marked deflav'mm capil-
lorum.

These patients^ indeed^ are for the most part led to consult a
medical man^ cliictly by the uneasiness which they feel on account of
the way the hair is coming off^ and of the quantity of scurf with
which the head is covered. In those cases in which the hair does
not fall out to so great an extent the disease is, at first, commonly
overlooked. For no subjective symptoms (such as pain or itching)
are, as yet, complained of, and the only morbid condition is tlie
presence of pellicles of sebum upon the surface of the face and
head.

It is only at a later period, when the affection has existed for
some time, that itching of the head occurs, which, together with
the (leßtivium ca/pillonm, leads the individual to seek medical
advice.

In the majority of these cases the patients are chlorotic girls ;
and even those males who are affected with this form of seborrhoea
are generally in a condition analogous to chlorosis. Other diseases,
however, by which the nutrition of the body is impaired, are very
frequently followed by the falling off of the hair and the scurfy state
of the head, characteristic of the complaint which I am now
describing. Thus, we see it after typhus, measles, scarlatina, small-
pox, and other febrile diseases; and it may also arise in women
recently confined, during the period of lactation, and in persons
affected with tuberculosis, syphilis, or a chronic form of cancer.

In some instances, however, it is difficult to show that this affec-
tion, and the defluv'mm caplllormn which accompanies it, are con-
nected with any local or general disease. Tor we sometimes find
seborrhoea occurring in persons who enjoy good health and are well-
nourished ; and although, in these cases, the complaint often quickly
subsides, yet it is , occasionally prolonged. Under these circum-
stances, we know absolutely nothing of its predisposing or deter-
mining cause«.

It may, indeed, be noticed that, as a rule, seborrhoea is, in healthy
persons, confined to the scalp, and attacks particularly the anterior
part of this region, corresponding to the distribution of the frontal
nerve. Sometimes, however, the face also is slightly affected,
a few minute scales making their appearance at different points on
its surface.

The selorrhcea oleosa of the face, again, is accompanied, in most

118 AFFECTIONS OF THE SEBACEOUS SECRETION.

instances^ by a scaly affection of the scalp. It occurs both in
persons who are well-nourished^ or even fat^ and also in those who
are in the habit of drinking spirits to excess^ and in whom the liver
has undergone fatty degeneration.

This is, indeed, a point to which I would draw the especial atten-
tion of those who are interested in the study of pathology and
morbid anatomy. For it is an established fact that the sebaceous
secretion of spirit drinkers (and, consequently, of persons with fatty
livers) is particularly soft and oily. Hence the skin of these indi-
viduals has a peculiarly smooth and greasy feel. Hence, also, the
ducts of the glands in these people are never obstructed by plugs of
sebum (comedones) . In fact, unless their position is indicated by
the exit of minute hairs at the sauie points, the apertures of these
ducts are distinguishable only by a practised eye and on careful
examination.

Treatment. — This may, of course, be either general or local: on
the one hand, internal remedies may be administered ; on the other
hand, external applications may be employed. In many instances,
however, the seborrhoea is not the result of any constitutional
malady, or at any rate, is due to causes concerning w^hich we are
altogether in the dark. Hence I prescribe internal medicines in
those cases only in which local apphcations have proved unsuccess-
ful, or in which some demonstrable disease of the system may be
supposed to give rise to this affection.

Now, experience has shown that those agents which improve the
nutrition of the body generally, and favour the process of sanguifica-
tion, are most effectual in removing seborrhoea.

In suitable cases, therefore, we may first prescribe the common
bitter medicines, such as the Infusiim Millefolii, the Trifolium Fibri-
mim, the Radix Calami Äromatici, the E. Zingiieris, or the R.
Cardui Benedicti ; subsequently, we may in some cases give quinine,
or the Decoctum Cinchona ; and, finally, we may have recourse to
arsenic.

Whenever the patient is evidently suffering from anaemia, chlorosis,
or any similar condition, our internal treatment should, of course,
mainly consist in the administration of preparations of iron. Under
these circumstances, I have often used, with advantage, the com-
bination of iron and arsenic proposed by Erasmus Wilson, and which
he terms the 3Iist. Ferro-arsenicalis. The formula for it is as fol-
lows :

TREATMENT OF SEBORRHCEA. 119

Jt Viui Perri, 3153 ;
S^T. Simpl. ;

Liq. Potassse Arsenitis, S ^ij ;
Aq. Destill., 3!] ;

a drachm to be taken three times daily with the meal.

Should the Yinum Ferri disagree with the patient, the Tinctura
Ferri Malatis may be substituted for it. The jjrescription which ]
give in such a case is the following :

J^ Tiuct. Ferri Malatis, 3J ;
Liq. Potassse Arseuitis, 5j ;
Aq. Meutbfie, 3iv;

" a tenth part to be taken every day before dinner.'"'

It must be borne in mind that the full effect of any of these
medicines can be obtained only by continuing their use for several
months at least, and in gradually increasing doses.

I must express my conviction that, in these cases, it is quite use-
less to adopt an eliminant method of treatment, or to prescrilje any
of those medicines which are supposed to act as '' purifiers of the
blood/'' Purgatives and the Decoct. Sarzas Comp, are alike inert
in seborrhoea ; indeed, they may even be injurious.

Accordingly, the diet of these patients shonld be nutritious in
pro]3ortion to their digestive powers, and their mode of life, in other
respects, should also be regulated.

The local treatment of seborrhea must vary with the seat of the
disease. In any case, however, the first point is to get rid of any
masses of sebaceous secretion which may be present. Por this
purpose we must make use of agents which soften or dissolve this
substance. Simple ablutions with water, or the application of the
douche, will effect its removal only after a considerable time, whereas
this may be done very much more quickly by rubbing into the part
some fatty or oily substance, or even alcohol or ether.

It is, however, necessary to remember that, when this complaint
has lasted a long time, and crusts of some thickness have been
formed, they must be slo^^'ly and gradually removed ; otherwise the
patient is very likely to suppose that the sudden separation of
these accumulations of sebum is the cause of the loss of his hair.
For it almost always happens that the same condition which gives
rise to the seborrhoea causes the hairs which grow on the part to be
ill-nourished. Hence, even when thev do not all fall out they often

120 AFFECTIONS OF THE SEBACEOUS SECRETION.

become so loose that thej may be drawn from their sacs by a very
slight amount of force ; or_, indeed^ they may actually become de-
tached and yet be kept in their places by the masses of sebum^ so
that the scalp appears still to be well covered.

Now, if, under such circumstances, we suddenly remove the crusts
in which the shafts of the hairs are imbedded, these will, of course,
come away at the same time, and unless we are prepared for this
result we shall be mortified and our patient disgusted at finding that
he has all at once become bald.

It is, then, advisable, in these cases, either to avoid getting rid
too hastily of these masses of sebum, or, at any rate, to tell the
patient beforehand what will be the efifect of our treatment. This
may, for instance, be done by first puUing out a few of the hairs,
and showing to him that their roots are no longer imbedded in the
skin, being kept in place merely by their attachment to the crusts,
with Avhich, therefore, they must necessarily fall off.

Having, then, with due caution, softened and removed the masses
of sebum, we must thoroughly wash the part affected with soap and
water. This is to be done several times in all cases, even though
the skin may become red and shining, and though, at one or two
points, a little oozing (Nässen) from its surface may take place.

The integument having been thus cleansed, some ointment or
fatty substance should be again applied, both for the purpose of
relieving the very unpleasant feeling of tensio]i left by the operation
of washing, and also to prevent fresh scales being formed, which
would otherwise quickly occur.

I do not think that, under these circumstances, it makes any
difference whether we employ simple lard, or an ointment containing
a small quantity of oxide of zinc, white precipitate, tannin, or qui-
nine. In any case the good effects ought probably to be ascribed
to the lard alone. If, however, the patient complains of itching
after the scales have been removed, it will very likely be useful to
apply, with a brush, a mixture containing the 01. cadinum and alco-
hol in equal parts, or to wash the surface of the skin with a weak
solution of carbolic acid. Tor this purpose I make use of the
followincr formula: —

|l Acid. Carbolic, gr. x ;
Glycerrhinse ;
Alcohol., Aq. Destill. seu Aq. Lavandulse, ä 3ss.

COMEDONES. 121

The whole process I have been describing (including the inunc-
tion of oil, washing the part with soap and water, and, finally, the
application of lard or of some ointment) must be repeated every
twenty-four hours until the itching ceases and fresh scales are no
longer formed. By this time the hair will have begun to re-appear
or Avill liave acquired a more vigorous growth.

When seborrhcEa affects, not the scalp, but the face or some part
of the trunk, it yields much more readily to the treatment I have
• been describing. In such cases it is seldom necessary to employ
any of the preparations of tar.

Prognosis. — In the different varieties of seborrhcea the prognosis
depends mainly on the cause of the disease. Those forms of it
which may be regarded as physiological are of less consequence
than any others, while the most unfavorable of all are those associated
with cancer, tuberculosis, syphilis, or some other internal malady.
The liability to relapses follows the same rule.

As for the baldness to which these affections give rise, it is seldom
merely transient ; that is to say, the growth of the hairs is rarely
afterwards restored to its normal condition. Those subsequently
developed are generally shorter, thinner, and less richly supplied
with pigment than before. Even though their number may not be
diminished, these hairs form merely a scanty, thin, colourless down,
which is a very poor covering to the head of the patient.

2. Affections in wliicli the sebum is secreted in excessive qiumt'ity ;
its excretion being, at the same time, interfered with.

Excepting the lupus erythematosus, the diseases hitherto de.
scribed in this chapter are all attended with a great increase in the
production of sebum, which at once reaches the cutaneous surface,
there being no obstacle to its excretion. But even in these dis-
eases we generally find some of the ducts plugged up by masses of
sebaceous secretion which have long borne the name of comedones
(acne punctata).

Now, although, so far as we know, comedones arise only when
the escape of the sebum, after its secretion, is in some way pre-
vented, yet the fact that seborrhcea (especially the form of it which
affects the face) is commonly associated with their presence appears
to show that the same condition which produces the one also causes
the development of the other affection.

122 AFFECTIONS OF THE SEBACEOL'S SECRETION.

It is^ however, necessary, for many reasons, that I should give a spe-
cial account of comedones. Thus, the appearances to which this affec-
tion gives rise are entirely different from those of seborrhoea. Indeed,
by the extreme enlargement of comedones, or by the coalescence of
several of them into a single mass, certain peculiar wart-like bodies
are formed, Avhich were described by myself, in 1842, under the
name of sebaceous warts (Sebumwarzen), and have been termed, by
Eibbentrop,^ Coinedonenscheibcn. Moreover, the presence of come-
dones often sets up an inflammation of the folHcles, which would
naturally be termed ^ifoUiciiUtis, but has been generally called acne
(lonthus. Varus).

Again, there are, besides these^ several other diseases of a similar
origin. Such is that which is known as Milium or Grtdnm, or, ac-
cording to Willan, as Sirophuliis albidus, and S. candidus ; that
which has been termed Vililigoidea ; and, lastly, that which re-
ceived from "NYillan the odd appellation of Molluscum contagiosum.,
and which consists in the formation of semiglobular elevations
resembling vesicles. All these morbid conditions can be shown to
belong to an uninterrupted series, and to be seated in the sebaceous
glands, of which, sometimes, one alone is affected, whereas in others
among these diseases several adjacent glands are simultaneously in-
volved.

Comedones.

These, as we all know, are small dark points, seldom raised above
the level of the skin, and easily squeezed from their bed by pressure
applied on each side of them. The black spots are then seen to
form the summit of worm-like bodies, which were, indeed, formerly
supposed to be minute worms, and are generally of some length, and
of a whitish, whitish-yellow, or yellow colour. This affection is
observed chiefly on the face, chest, and back.

These masses may be easily examined after their removal from
either the living or the dead body; they are then found to consist of
sebum, which has accumulated and been retained within the canals
common to the sebaceous glands and the hair-sacs.

Comedones are sometunes solitary, sometimes collected together
in groups. They vary in size between that of a pin's point and that

' ■Rust's 'Magazin,' Band Ixiv, ).845, Heft i.

COMEDONES. 123

of its head. The colour of their free extremity is not always the
same.

If we watch a comedo, at intervals, for a considerable time, we
often find that it remains altogether unaltered. The affection then
causes great disfigurement, for the face of the patient looks as if
grains of gunpowder had been introduced into the substance of the
skin. Other comedones, however, undergo spontaneous involution ;
the sebum which had accumulated is gradually extruded from the
mouth of the duct, and the gland is restored to its normal con-
dition. In this case, the affection does not return, unless, indeed,
the excretory canal should again become obstructed. It has, then,
been ascertained, by direct observation, that it is possible for come-
dones to disappear of themselves, and that when this occurs no
further morbid changes are observed.

This important fact is, indeed, my justification for describing
acne, and the affection now under consideration, apart from one
another. Por although I admit that comedones may be the cause of
acne, by irritating the surrounding parts or in other ways, yet it
appears to me that there is so great a difference between the two
diseases as to render it advisable that they should be treated of
separately. I must, therefore, refer the reader to the second
volume of this book for an account of acne.

The investigations of Krause, Simon, von Bärensprung, Er.
Wilson, and KöUiker have shown that comedones are caused by an
accumulation of the sebaceous secretion, not only in the glands
themselves, but also in the canals common to them and the hair-sacs.
These masses generally contain, besides the sebum, minute hairs in
greater or less numbers, some of which are rolled up spirally.

Lastly, the Acutus foUlculomm is very often, although not con-
stantly, present in comedones. This parasite was first detected by
Henle^ in the ceruminous glands ; a little later it was discovered
independently by Gustav Simon^ in dilated hair-sacs and sebaceous
glands, and subsequently the same observer found it in these
glands Mdiüe in the normal state. Its existence is, at the present
time, generally recognised; and with a little dexterity it may be
very easily brought into view.

For this purpose it is no longer necessary to examine comedones

' 'Beobacbtungeu aus der Oestlicben Schweiz/ Dec, 1841.
- 'Med. Zeitung von dem Verein für Preussen/ 1842.. No. 9. Müller'a
* Archiv für Anatomie,' 1842,

124 ArrECTioNS of the sebaceous secretion.

themselves. We now simply scrape with the edge of a knife the
foreheadj or some other part of the skin of a person affected with
this parasite. In this way we collect a quantity of sebum mixed
with masses of epidermis ; and when this material has been softened
by the addition of a little oil^ the animal may be sought for in it
with success. It may be very well seen with a magnifying power of
400 diameters.

The Acarus folliculorum appears to vary greatly in length and
form, according to the stage of development at which it is
examined.

The following account of this parasite is given by Simon : — '^ In
the form most frequently observed the Acarus follmdorum is from
0-085'" to 0-125'" in length, and about 0-020"' broad. The head is
provided with two lateral two-pointed palpi, and a long tubular
proboscis, upon which is a triangular organ, made up of two fine
points or bristles. The head passes immediately into the thorax,
which makes up about a fourth of the whole length of the animal.
On eacli side of the thorax there are four very short, conical feet,
consisting of three segments, and bearing three narrow claws at their
free extremities. Trom the base of each foot a ridge (Streifen)
extends transversely across the thorax ; and these transverse bands
are all coimected together by a longitudinal ridge placed in the
median line.

" The abdomen is about three times as long as the chest ; its in-
tegument presents a number of constrictions, which are %tt\\ as
transverse lines placed close to one another, and give a notched
appearance (hke that of a file) to its lateral edges.

"Another form of this animal is characterised by the shortness of
the abdomen, which may not be longer than the thorax, and is, at
any rate, not more than half as long again as that region.

*^ A third variety of the Acarus folliculorum offers the peculiarity
that it has only three pairs of feet instead of the four which are
usually present. The abdomen, too, is perfectly smootli, the trans-
verse lines being altogether wanting. Erichsen supposes this form
of the animal to be the youngest, that fii-st described to be the next
in order, and the other (with the short abdomen) to be in a still later
stage of development." Indeed, this observer believes that, in the
fully formed acarus, the abdomen is entirely obsolete.

There is also a fourth variety of this parasite, which has a cordate
form. This was first recognised by Simon, who gave a drawing of it.

COMEDONES. 125

Wedl states that he has very frequently observed it, and supposes
it to constitute the earliest stage in the development of the acarus.
His main reason for this opinion is that he has several times quite
plainly seen sucli a cordate body within the anterior part of the
abdomen of another animal.

Various names have been given to this parasite by different
writers. Simon named it the Äca?-tisJblliculonci/i; Owen, the De-
i/iode.v follicularis ; Miescher, the Macrogaster Plat^jms ; P.Gervais,
the Simonea folliculorum ; E. Wilson, the Entozoon folliculare
and the Steatozoon folliculare. According to Th. von Siebold it
belongs to the Acarina.

Gruby asserts that, having transferred this parasite to a dog, he
afterwards found the animal to be affected with other acari belonging
to the very same species ; and that in the course of two years these
increased enormously in numbers, so that every one of the cutaneous
glands became affected by them, and the dog, in consequence, lost
its hair. Simon and Wedl, however, have cast doubts upon these
statements. Oschatz maintains that he has found a similar parasite
in the glands of the eyelids of a sheep.

Although the Acarus follicidorwn, even when it is present in
enormous numbers, generally produces no obvious symptoms, Simon,
nevertheless, admits the possibility that it may in some cases lead to
the formation of comedones and acne-pustules. Indeed, Remak has
recorded the case of a person severely affected with acne of the nose
and chin, of whicli complaint this parasite was supposed to be the
cause. But in this instance it was only after searching for a long
time and with great trouble that Eemak succeeded in extracting
the animal from the bottom of a few of the pustules, sometimes at
the depth of a line from the surface of the skin.

In my opinion there is no ground for the belief that the Acarus
folliculorum ever gives rise to either of the affections which I have
named. Indeed, we actually fail to find it in comedones and within
the tubercles of acne more often than in the sebaceous glands of
individuals whose skin is particularly smooth and delicate. Tor in
such persons this parasite may frequently be discovered by the
method above described.

126 AFFECTIONS OF TUE SEBACEOUS SECRETION.

Milium seu Grutum.

Having now given a full accoinit of the ordinary comedo, I
naturally pass on to describe the affection which is known as milium
or grutum, and consists in the formation of little^ rounds white bodies,
sometimes isolated, sometimes aggregated together. These bodies
lie beneath the epidermis, and when this is divided, they may be
easily removed by applying pressure on each side of them.

This affection is observed most commonly on the surface of the
eyelids and cheeks, on the red part of the lips, and on the male and
female genital organs. Round the corona glanclis the little round
bodies which I have been describing may often be seen crowded
together in enormous numbers; and they are also found on the
dorsum penis, the prepuce, and the scrotum, where they frequently
lie close to the spots at which hairs emerge from the skin. The
parts of the female external organs most frequently affected in this
way are the nymphsc, the internal surfaces of which, for instance, often
contain hundreds of them, and present, in consequence, a coarsely
glandular aspect.

The following are the chief points of distinction between the
comedo and the milium. The former occupies the canal of a hair-
sac, and is therefore in direct communication with the cutaneous
surface. Indeed, it owes to this circumstance its black "head,"
which simply consists of particles of dirt, adhering to the fatty sub-
stance of which the comedo is made up. On the other hand,
no dust or dirt has access to the milium, for this little round body
lies beneath the cuticle, which forms a continuous covering over
it. Iiloreover, the seat of this affection is not the duct, but the
sebaceous gland itself, or, more probably, a single lobule of this
organ.

I believe, then, that the milium consists of a sebaceous gland (or
only a lobule of such a gland), filled with its secretion, and no
longer connected with the hair-sac, into which it previously opened,
but forming an independent body imbedded in the substance of the
skin. I may surely urge in favour of this view the fact that these
little round laodies are frequently found where operations have been
performed. Thus, they may often be observed oh either side of a
linear cicatrix, this being probably due to the fact that several

MILIUM, VITILIGOIDEA. 127

lobules of sebaceous glands, cut across wlieu the incision was made,
have remained isolated, and have subsequently become distended
with sebum.

These globular bodies may also frequently be noticed to be
present, in large numbers, on regions affected with some other
cutaneous disease, such as lupus. In this case, too, it is probable
that they arise in a similar way, for, in the course of the formative
and destructive changes which constitute lupus, certain sebaceous
glands are very likely to have become separated from the hair-sac,
or some of the lobules of such glands, from the rest of them.

But whatever may be the nature of the change wdiich leads to the
production of milium, it is at any rate certain that these little round
white bodies lie merely beneath the cuticle, and are not attached to
any of the deeper structures; being fixed only by the lamina of epi-
dermis which covers them. This is easily shown by the fact that
they escape at once, as soon as an incision is made into the epider-
mis which confines them. Indeed, they are sometimes cast o
spontaneously, when their cuticular covering is removed in the
course of the physiological changes which it undergoes ; and thus
Avhole groups of these little bodies may be got rid of at the same
time.

Vitiligoiclea.

This is another affection which arises from a morbid change in the
sebaceous glands. It received the name of Yitiligoidea from the
late Dr. Addison ^ and Dr. Gull, who described two varieties of itj
the V. plana and the V. talerosa.

Mr. Erasmus Wilson, being dissatisfied with the name given to
this disease by the waiters Avhom I have quoted, has proposed for it
the title of La?nin(B flavcB ejiithelii cutis. He is of opinion that, in
this complaint, it is the layer of epidermis lining the follicles which
is affected, rather than the glands themselves and their contents.
He thinks that the nodules formed in Vitiligoidea arise from a
yellow hypertrophy of the epithelium which lines the sebaceous
glands. This, indeed, was not the opinion originally held by Mr.
AYilson. He at first regarded this affection as due to a morbid
change in the glands themselves, and gave to it the name of

' 'Guy's Hos^pilal lleports,' 2iul series, vol. vii, p. 2, vol. viii, p, 149.

128 AFFECTIONS OF THE SEBACEOUS SECRETION.

Molluscum sebaceum. But lie was subsequently led to adopt a
different view by findiiig that, having punctured one of the nodules,
he was unable to squeeze out the yellow body which lay beneath the
epidermis.

Now I cannot but think that, if Mr. Wilson had made an incision
through the tubercle instead of simply pricking the cuticle over it,
he would have adhered to his first opinion. Tor, in the cases which
have come under my observation, on cutting across the epidermic
covering and applying pressure to the sides of the incision, a sub-
stance has at once escaped which, when examined, has been found to
differ from the ordinary sebaceous secretion only in being of a firmer
consistence, and, indeed, in having a more marked yellow colour.

I must also point out that this affection maybe detected in many
persons on the upper and lower eyelids, and even on some other
parts of the face. Its presence is discovered by stretching the skin
forcibly, and making a tolerably deep incision into the whitish or
yellowish patches, which then come into view. On applying pres-
sure to the sides of the wound, tliere escape masses of degenerated
sebum which had accumulated within the cutis.

According to the description given of it by Addison and Gull,
this disease "presents itself under two forms, namely, either as
tubercles, varying from the size of a pin's head to that of a large
pea, isolated or confluent; or, secondly, as yellowish patches of
irregular outline, slightly elevated, and with but little hardness.
Either of these forms may occur separately, or the two may be com-
bined in the same individual. Under the latter circumstances, we
are able to trace the connection of the two through an intermediate
series of gradations, >vhich clearly demonstrate their essential
relations."

Up to the time of the publication of these papers in the ' Guy's
Hospital Eeports,' five cases of Yitiligoidca had come under the
notice of the physicians whose observations I have been quoting.
Tour of these cases occurred in women, while the remaining
patient was a man. The affection was seated on the face (including
the eyelids and ears), as well as on other parts of the body, such as
the elbows and both the dorsal and palmar surfaces of the hands.
In every instance the tubercles developed themselves very slowly,
and at length passed into a stationary condition, after which they
underwent no further changes.

I must not omit to state that in three of these five cases of

VITILIGOIDEA. l29

A'itiligoidea^ the skiu-afi'ection was preceded by jaundice ; and thai,
in another of them, diabetes was present. In the remaining case, no
mention is made of the coexistence of any other malady.

Eroni the account of this complaint given by Addison and Gull,
and also from the plates which accompany their papers, it is easy to
perceive that the cutis itself could not have been the only structure
atfected in the cases which came under their observation. In fact, I
am convinced that Vitihgoidea consists in a peculiar degeneration of
the sebum, and the glands which secrete this substance ; and that
this disease is allied to other cutaneous affections which have long
been well known, and particularly to that form of milium which I
have already mentioned as occurring on the red part of the lips, on
the nymphse, and round the corona of the glans penis.

It is true that the second and the fourth of the cases recorded by
these writers presented a feature which is opposed to the opinion I have
advanced. In these instances the affection occurred on the palms
of the hands, where no sebaceous glands have as yet been dis-
covered in the skin. However, on the dorsal surfaces of the fingers,
and particularly o^r the joints between the jSrst and second
phalanges of one hand, the appearance of the tubercles is exactly the
same as on the other parts of the body.

The drawings given by Mr. A¥ilsoni likewise show plainly that the
seat of this disease must be looked for in the sebaceous glands.
Tor, in these figures, also, we observe tubercles, some of which are
isolated and some confluent, but which all correspond to distended
glands, and resemble the elevations which constitute milium.

As I have already stated, in each of the two cases of Vitiligoidea
which have come under my observation I succeeded in squeezing
out the morbid material from the cavities in which it lay, by apply-
ing pressure, after having made an incision through the cuticle.
The fatty substance which I thus obtained was of firm consistence,
and of a yellow or at any rate a yellowish colour, and resembled the
sebaceous secretion.^

' Op. cit., 1863, plate xvi.

" It is stated by Drs. Addison and Gull (op. cit., vol. vii, p. 268), that, in
the case of Jolm SheiifF, "many of the nodviles were not unlike the ordinary
molluscum, but, when incised uith a lancet, they were found to consist of firm
tissue, W'hich, on pressure, gave out no fluid save blood."

There is, at the present time (June, 1866), in Guy's Hospital, a woman,
set. 39, affected with this remarkable disease. She is a patient of Dr. Pavy;

lau .VrFECTIONS Üt' TUE SEBACliOUH SECllETION,

Sebaceous Warts and Tmaours.

Appearances of a very different kind from those wliicli I have
been hitherto describing are produced when comedones form in fol-
licles placed close to one another. Under these circumstances^ if
the excretory canals are closed, and the secretion of sebum goes on,
the glands keep increasing in size till at length they come into con-
tact, and coalesce into a single mass, which may be regarded as
being, in fact, a gigantic comedo. These bodies bear a great resem-
blance to the common warts, arising from the hypertrophy of
papillae, and the more so because tliey in time acquire a darker
colour, and become gradually harder than they were when first
formed.

I must also mention another peculiar form of this affection,
likewise due to an accumulation of sebum in a gland (or in several

she has been the subject of jaundice for three years ; and her liver is much en-
larged. In this woman, the palms of the hands are involved in the complaint,
and it also extends to the under part of the heel, and occupies the plantar
surfaces of the toes. At all these points, unprovided with sebaceous glands,
the disease takes the form of the V. plana ; while, on the dorsal aspects of the
fingers, on the skin of the pinna of the ear, and at other parts of the body,
it appears as the V. tuberosa. Kound the eyelids, however, where the skin of
course contains sebaceous glands, there are patches of the V. lüana.

It, therefore, appears evident that the complaint cannot universally consist
in an alteration of the sebaceous glands. It might, however, be that the raised
growths on the fingers and elsewhere arise, in part, from an accumulation of
sebum. The microscopical examination of one of these masses removed from
the living patient did not lead to the conclusion that this was the case. On
cutting across the growth, it was found impossible to squeeze out any of the
yellow masses which came into view. These were nearly as hard as cartilage,
and contained a good deal of fibrous tissue and a large quantity of granular
matter, very similar to that found in the atheroma of arteries (as was suggested
by Dr. Moxon), No cells were found in these growths, and the most careful
examination failed to show that the sebaceous glabds were in any way con-
cerned in the production of the disease.

A full account of this case will be found in the ' Guy's Hospital Eeports,'
1866, ser. iti, vol. xii.

It may be worth while to mention that, since the publication of the paper
by Addison and Gull, another case besides this has occurred at Guy's Hospital.
In this patient, also, the Vitiligoidea was associated with jaundice. — [Ed.]

MOLLUSCUM CONTAGIOSUM. 131

glands which have coalesced), but differing from that just described,
in the fact that it does not resemble a wart, because the comedones
of which it consists do not all project freely upon the surface of the
cuticle. In' the complaint to wliich I now refer the comedo which
occupies the middle of the mass is alone visible externally ; the
others being covered with epidermis, and merely forming elevations
above the level of the skin. This affection resembles, to some
extent, a smallpox pustule. It has in its centre a small depression,
which may be compared to an umbilicus, and may be observed to
contain a minute plug of sebum, either of a white or dark coloui".
This little pit is surrounded by a raised border covered with
healthy cuticle. If pressure be applied to the sides of one of these
small tumours the central comedo protrudes, and the whole mass is
emptied of its contents.

As long ago as 1842-44 I alluded to this affection, both in my
lectures and in my annual reports on dermatology ; and at that time
I drew attention to the fact that it is observed especially in persons
who suffer from prurigo. Subsequently Dr. Ribbentrop,i of Berlin,
described the same disease under the name of Comedonenscheiben,
and explained the various forms which it presents by attributing
them to differences in the composition of the sebum, this being
sometimes hard, and containing a large quantity of stearine and cal-
careous salts, while in other instances it has less of these constituents,
and is, therefore, softer.

Molluscum contagiosum.

This is a cutaneous disease, which depends upon conditions of
the same kind as those to which the affections just described owe
their origin.

" This singular eruption,^' says Bateman,2 " had not been noticed
by Dr. Willan, and was unknown to myself till after the publication
of two editions of my Synopsis."

The term MoUnscnm had, indeed, been previously applied by
Willan to an affection attended with the formation of solid tubercles,

1 ' Eutwickelungsgescliichte der Comedoueu und Atherome;' 'Kust's Maga-
zin,' B. Ixiv, 1845.
- 'Delineations of Cutaneous Diseases,' &c., 1817.

132 AFFECTIONS OF THE SEBACEOUS SECRETION.

M'hicli are moveable, possess but slight seusibilitv, and have an
clastic feel; but in the Molluscum contagiosum of Batemau the
tubercles contain a milky fluid, which, on the application of
shght pressure to the side of the mass, is -easily made to escape
through an aperture, previously almost imperceptible, in its
summit.

Now, it is quite true that tumours of the same colour as the rest
of the skin, sometimes stalked, sometimes sessile, varying in size
from that of a pea to that of a child's head, are not unfrequently
formed on the cutaneous surface ; and that the interior of these
tumours is in some cases solid, and made up of areolar tissue, while
in other instances it consists of sebum, which, especially if it is fluid,
may easily be scjueezed out uj)on the surface of the skin through a
still pervious follicular aperture.

If this afl'ection is to be termed Molluscum, we may distinguish
the two varieties of it by naming the one Molluscum fihrosum, or
(as Virchowi has it) Fibroma violluscum, and the other Molluscnm.
sehaceum s. contagiosum?

We are, however, at present concerned only with the latter of
these two forms. For the cutaneous diseases to which the names
Molluscum non-contagtosum,M. pendulum, were formerly given, come
under a difi'erent head in ray system of classification; and the same
may be said of the affection termed mycosis by Alibert, and also of
tlie case handed down from the last century by Tilesius and Ludwig."

It is probable that the term molluscuui had before been commonly
employed to designate tumours raised above the surface of the skin,
and of a wart-like appearance. For Plenck"^ gave to one of bis
species of warts the name of Verruca carnea, s. raollusca, and de-
scribes this affection in the following terms: — "Est tuberculum
moUe, sensile, cuti concolor, vcl rubens, srepe pilosum ; in iiaso et
facie ut plurimum invenitur. Videtur admodum magna cutanea
glandula quasi esse."

Xo one, however, has done so much to make the 3Iolluscum coa-
tagiosum generally known to the profession as Batemau, who first

' 'Die kraakliaften Geschwülste,' i3te Vorlesuug, p. 327 ; Berlin, 1863.
Ibid., lite Vorlesung, p. 222.

^ 'Hist. Pathologica singularis cutis turpitudinis J. G. llheinliardi,
gezeiclmet luid mitgetlieilt vou Tilesius, mit einer Vorrede, von Prof. C. i\
Ludwig'; Leipzig, 1793.

■* 'Doctr. de morbis cutaneis,' ed. 2da. aucta, Vienusc, 1783, p. 97.

MOLLUSCUM CONTAGIOSUM. ]33

gave this name to the disease, aud described and figured it in his
continuation of the work of Willan.

According to the definition given by this observer this disease
differs from the other species of molluscura chiefly in being com-
municable, to other persons, the milky fluid contained in the larger
tubercles being the medium by which the contagion is conveyed.

Later writers, however, seem not to be agreed as to the conta-
gious nature of this affection, the difference in their views probably
arising from the fact that they have not all had equally good oppor-
tunities of observing cases of molluscum.

Carswell and Thompson^ for instance^ relate that a boy affected
with this disease communicated it to a schoolfellow, by whom it
was again transferred to his brother, a child at the breast, and so to
his mother. These observers^ however, give no details which might
enable us to determine whether the complaint in these cases was
really that described by Bateman or one of a different nature.

Alibert collects together various cutaneous affections, some
syphilitic, some not so, but all attended with the formation of
fungous growths, and jumbles them pele-mele together into one
genus, to which he gives the name of Mycosis. He refers to
the case of Carswell, as being an instance of his Mycosis fun g aides.

The later Trench writers seem likewise to be imperfectly ac-
(piainted with the disease with which we are now concerned. Thus,
Biett says that the Molluscum contagiosum is a very rare affection
which had not, up to the time ^vhen he wrote, been observed in
France. Again, Cazenave and Schedel, Gibert, and Duchesne-
Duparc make only cursory allusions to it, and no one of these derma-
tologists gives any detailed account of it.

To this rule Eayer is, indeed, an honorable exception ; for this
writer not only describes in regular order all the various affections
produced by retention of the sebum and dilatation of the sebaceous
glands, but also displays an accurate acquaintance with the Mollus-
cum contagiosum of Bateman.

A few German writers (namely Frank, Eiecke, Fuchs, Simon, and
von Bärensprung) mention this affection when describing warts,
comedones, or encysted tumours. They give, however, but an im-
perfect account of it, aud therefore we must conclude that but few
cases of it had come under their observation.

In the year 1845 I had, with Eokitansky and Engel, an oppor-
tunity of examining a small number of patients affected with Mollus-

134 AFFECTIONS OF THE SEBACEOUS SECRETION.

cum contagiosum. I shall subsequently state the conclusions at
"which I arrived concerning this disease.

The monograph on the subject of molluscum; by Dr. Jako-
bowich (Jacobovics) of Vienna, although published in the Erench
language, is of German origin, and may be said to belong to Ger-
man literature. But of the plates appended to this treatise some re-
present mihum and comedones, others teleangiectases, and others even
belong to macular affections. Indeed, the only case of molluscum
contained in this work is that of Tilesius, which is an instance of
M. non-contagiosum, and which Jakobowich describes in a style
more suited for lay than for medical readers.

This treatise then, which is quoted in almost every work on
dermatology, is far from possessing the scientific value which would
entitle it to such general notice. Dr. Jakobowich, indeed, never
devoted himself to this special branch of medical practice ; and his
object in publishing a book on molluscum was to make more gene-
rally known in Germany an affection which had, up to that time,
attracted but httle attention in that country.

The works of Englisli writers make up the greater part of the
literature of molluscum. Plumbe, indeed, does not mention it; but
Jon. Green, A. T. Thomson, Er. Wilson, Jones, Patterson, Hender-
son, Carswell, Tilbury Eox, and HilHer, may be named as having
given a full account of it in works written by them, or as having
pubHshed in the medical journals cases of this disease, with the
results of their investigations upon it. Among the authors I
have named there is a general agreement as to most of the characters
of this complaint, and particularly with reference to its form and
seat. But in one point they differ, for some of them believe that it
is, and others that it is not, contagious. Of these opinions the
latter is the one which I myself hold.^

1 111 Plate IX of the ' Atlas of Portraits of Skiu Diseases,' published by the
New Sydenham Society, a figure is given of the face of a child affected with
this disease, and the same plate also contains a drawing of the breast of this
child's mother, who was still suckliug. On the woman's breast are several little
tumours, precisely similar to those on the infant's face. This instance of
the apparent transmission of the complaint from one person to another was
under the observation of Mr. J. Hutchinson, who tells me that he has several
times seen the same thing. I believe that in most, if not in all cases, in which
the communication of this disease has been supposed to occur, the individual
first affected has been a child; and most English observers certainly do not
regard as contagious the form, of molluscum in which numerous pendulous

MOLLUSCUM CONTAGIOSUM. 135

Having now referred fully to the literature of this subject, I may
pass on to define the term Molluscum contagiosum. This expression
is synonymous with the " tumeurs folliculeuses ■" of Eayer.^ It is,
at the present day, applied to an affection which consists in the
formation of tumours, varying in size from that of a lentil to that of
a man^s fist, either stalked or sessile, of the colour of healthy skin
or shghtly tinged by pigment deposit. These tumours contain in
their interior a white material, which may be either hard or soft, or
may even form a milky fluid, but which, whatever its appearance,
can always be recognised as consisting essentially of sebaceous
secretion. By pressing the sides of these tumours their contents may
generally be squeezed out.

This affection is, in most cases, very slowly developed, and some-
times makes its appearance on parts at which a comedo (or an ob-
structed sebaceous gland) had previously been observed. It gives
rise neither to pain nor to itching.

In some instances these tumours resemble, at their commence-
ment, the sebaceous warts (Comedonenscheiben) of which I have
already spoken, but at other times they at first look like vesicleä.
In the majority of cases they are not bigger than peas, and it is
quite exceptional for one of them to grow as large as a man's fist.
The greater their size the more commonly are they pedunculated,
whereas the smaller tumours are invariably sessile.

When one of them is emptied of its contents, whether by acci-
dent or design, the dilated gland sometimes at once shrinks to its
original size, and the affection may then be said to be cured, without
the cyst-wall itself having been removed. But in other cases we find
that, after the discharge of the contained material, a red inflamma-
tory areola is formed round the cyst, which also becomes more or

or sessile tumours appear on the surface of the body in persons of advanced
age. It is, therefore, important to notice that Prof. Zeissl (who wrote the
chapter on ' Diseases of the Glandular Organs,' in the German edition of Prof.
Hebra's work) mentions incidentally that he has never seen this disease in
children. Zeissl also denies the contagiousness of moUuscum, and states that
"lie himself, Prof. Hebra, and several of his assistants, have repeatedly rubbed
the contents of several moUusca into the skin at various points without any
effect." If, however, the "moUusca," in these cases, were merely the sessile or
pedunculated tumours of adults, the failure of these experiments can hardly be
considered to settle the question at issue. — [Ed.]

' 'Traits Iheorique et pratiqne des Maladies de la peau,' Paris, 1835,
torn, iii, page 71^.

136 AFFECTIONS OF THE SEBACEOUS SECRETION.

less painful. A reactive iuflammation is^ in fact^ set up, resembling
that which is apt to arise round a comedo. The smaller, as well as
the larger, of these tumours are liable to be affected in this way,
and, as a consequence of this inflammatory action, their whole sub-
stance may break down and be eliminated.

Even when these tumours are very numerous their ])resence does
not in any way affect the healtli of the patient. Moreover, they
have no tendency to ulcerate or undergo induration. This affection
may therefore be said to be, sensu striclissimo, a cutaneous disease.

With reference to the cause of molluscum uo satisfactory explana-
tion has been given, either by the older dermatologists or by those
of the present day. For I cannot regard as satisfactory the expla-
nation of Hartmann, that it arises from a nisus cxcrescendi, nor the
statements of Rayer and others that it is hereditary, or produced by
continued pressure and " other conditions." In the cases which
have come under my observation it could not be shown that either
of the circumstances mentioned by Ilayer had anything to do with
the production of the tumours. Hence I prefer, for my own part, tq
confess my ignorance as to the mode of origin of molluscum, or, in-
deed, of milium, grutum, or sebaceous warts.

Perhaps, however, I ought to mention as a j^tredisposing cause of
molluscum the presence of other TDutaneous diseases, and parti-
cularly of jirnngo. In persons suffering from this last-mentioned
comj)laint, I have several times seen between the pruriginous
papules tubercles filled with sebum, some of which were small, but
others about as large as lentils.

Any one who may happen to have under his care a patient affected
with a large number of these little tumours will very soon convince
himself that the simplest method of treatment is at the same time
the best. Thus, I have found it easy to remove them with scissors,
by the knife, or by ligature ; or to destroy them by the application
of strong acids or caustic alkalies. But no mode of cure is so suc-
cessful, nor is any so quick, as the simple evacuation of their contents
by applying pressure with the fingers to the sides of these tumours.
Whether the contained matter be fluid or solid, I have always found
that as soon as it has been completely squeezed out a rather free
and continued hemorrhage has occurred, which, however, has been
easily checked by the simple application of charpie. Very soon
afterwards, within a few days at furthest, the empty cyst has been
withdrawn into the substance of the skin; and the patient has

DIMINUTION OF THIS SECRETION. 137

generally been cured of his disease without any suppuration having
occurred, a slight flat cicatrix being left when the crusts, formed of
dried blood, have become detached.

It is only when the tumours are of considerable size that it
may, perhaps, be necessary to remove them, or to make an incision
into them, and so evacuate their contents. For those which are
smaller, the procedure which I have described will always be found
sufficient.

This complaint is less liable to return at spots previously affected
by it, than on parts which may have hitherto remained free from
these tumours.

II. Affections in which the sebaceous secretion is diminished in
quantity/.

This condition may be recognised by its causing the skin, from
being insufficiently lubricated, to become dry, brittle, harsh, and
liable to chap. In some cases, moreover, the cutaneous surface
is covered with minute, white, branny scales, forming, in fact, the
affection which is known as pityriasis.

The decrease in the formation of sebum may be either local or
general.

As a local affection, it occurs chiefly in the hands, and is gene-
rally the result of the operation of some agent which removes from
the epidermis the material by which it is naturally lubricated.
Hence its different layers, being deprived of the substance which
should connect them together, are shed prematurely. In these cases,
too, the absence of fat renders the skin brittle, so that it cannot
yield when stretched by the muscular movements, and therefore
becomes chapped, and presents fissures (Ehagades). The extensor
surfaces of the fingers are especially liable to be affected in this way.

This condition is often observed in maid-servants, washerwomen,
and soap-boilers. AYillan termed it incorrectly the " tcashenooman' s
psoriasis" (Ps. lotricum). It would be better to speak of it simply
as a harshness of the cuticle, or to call it asperitudo epidermidis ; or,
if it be desired to employ a title which is not new, we may give it
the name of Pifi/riasis simplex localis.

A general deficiency in the secretion of sebum occurs in
marasmus senilis, and as an accompaniment of certain cutaneous

138 AFFECTIONS OF THE SEBACEOUS SECRETION.

diseases affecting the deeper structures of the skin. Thus it is met
with in prurigo, icUhyosis, and lichen ruler.

Prognosis. — When resulting from the presence of one of the com-
plaints just mentioned J this condition admits of no hope of a com-
plete cure. On the other hand^ the form of it produced by the
action of alkaline substances may be got rid of by removing its
cause ; whereas, if the operation of these agents is allowed to continue,
an eczema often appears at the spots on which the epidermis is
roughened. I may further remark that this condition is extremely
annoying to the patient, although it cannot be said to be an affection
of a very serious kind.

Diagnosis. — The brittleness and desquamation of the cuticle
{'Pityriasis simple.x-), which result from the defective lubrication of
the skin in these cases, might be mistaken for the effects of a chronic
eczema in process of cure, in the stage which has received the name
of Pityriasis rubra; but, in that condition, the spots at which
desquamation is going on are more or less thickened and reddened
by the previous inflammatory action. Moreover, vesicles either still
perfect or dried up are generally to be detected at some point or
other within the area of the part of the skin affected by the disease.

Treatment. — In the variety of this condition due to old age, or to
the presence of some other cutaneous disease, all that can be done is
to bring about, by artificial means, a more complete lubrication of
the skin. Now, we are not acquainted with any remedies which act
as stimulants to the sebaceous secretion in the same way as dia-
phoretics to the perspiration. Indeed, the defective formation of
sebum, or its total suppression, appears to arise in these cases from
the glands having undergone destruction. Hence the treatment of
these conditions can consist only in the application of bland, oily
substances, of animal or vegetable origin, to the parts affected, or
even to the whole cutaneous surface. Por this purpose, the 01.
morrhi(jß is particularly adapted ; but if its disagreeable smell forms
an objection to its use, fresh lard, butter, almond oil, or cocoa-nut
oil may be employed in its place. All fatty substances, however,
when exposed to the air for some time upon the surface of the body,
become oxidised and fetid, and then exert an irritant action upon
the skin. Hence, if the spots affected are of limited extent, they
must be washed every day with tepid water before. the oil is applied,
and when tlie whole surface of the skin requires lubrication, tlie
l)atient ought to take a warm bath at least every second day.

DIMINUTION OF THIS SECRETION. 139

When this condition results from the action of alkaline substances,
cold lotions must be at first employed, if the part is much congested,
and the epidermis partially destroyed. Subsequently, however,
when the redness has disappeared and desquamation has commenced,
we may, even in these cases, use oily applications.

CHAPTEß Yir.

CLASS IV.— EXUDATIONES CUTANEiE.

Diseases of ihe Shin caused hy Exudaiire Processes,

Although in iudividual cases it may be difficult, or even im-
possible, to draw the line where the appearances due to exudative
processes affecting the skin begin, and where those of hyperemia
end, yet we can point out, approximatively and in a general way,
tliose characters which indicate the presence of inflammatory products
in the cutaneous tissues. Thus, there can be no doubt as to the
nature of any case in which vesicles, bullre, or pustules, are present,
produced by the accumulation of serous or purulent fluid beneath
the epidermis. Again, any considerable thickening of the substance
of the skin, capable of being seen and measured — a swelling of its
structure, in fact — such as is observed in erysipelas, oedema, and
furunculosis, furnishes a proof that the cutaneous tissue is infil-
trated with matters poured out from the blood, or, in other words,
witli inflammatory products.

From their analogy witli the aS'ections to which I have just
referred, aiul particularly with the furunculi, it is easy to show that
other appearances also, including cutaneous tumours (Knollen),
tubercles, papules, wheals, and stigmata (Stippen), owe their origin,
for the most part, to similar processes.

In certain cases, however, no fluid inflammatory products exist,
nor is there any swelling of the skin, due to the presence of infiltrated
matters ; nor, on the other hand, is any circumscribed efflorescence to
be detected. Under such circumstances, it is often a matter of
considerable difficulty to determine the presence of an exudative
process. In order, then, to arrive at a correct conclusion we must
observe whether the skin is, in any degree, reddened or contains
pigment, and also whether there is any desquamation of the cuticle,
which, being developed abnormally under the influence of the Inflam-

ACUTE EXUDATIVE DERMATOSES. Ill

matoiy exudation, is in some of these cases continually being cast
off. For the hypersemise, strictly so called, do not present these
appearances of pigmentation and desquamation.

Now, just as inflammatory affections constitute the largest part
of the complaints to which other organs of the human body are
liable, so is it also with the diseases of the skin. A great majority
of the dermatoses, in fact, arise from exudative processes.

The skin-afl'ections belonging to this class being, then, so nume-
rous, we must subdivide them in some way, in order to obtain a
general view of tliem. As the basis of such a classilication of the
exudative dermatoses, I have adopted the course taken by these
diseases, because it enables me to separate a considerable number of
them from another group of no less size. Certain of these affections,
in fact, terminate within a short period of time; their duration is
definite, and may be foretold at their commencement ; and the
symptoms which they present for observation are of a somewhat
limited kind. But in others among them the development and in-
volution of the eruption take place much less quickly, and these
diseases are altogether of much longer duration, from the repeated
relapses which they undergo.

Adopting the usual mode of expression, I shall speak of the
former group of affections as acute, and of the latter, as chronic ; I
shall, in fact, divide the diseases of the skin, caused by inflammatory
processes, into two orders, the acute and the chronic.

Both these groups may be further subdivided in various ways :
according to their causes, into the contagious and the non-contagious,
the idiopathic and the symptomatic, the protopathic and the deutero-
pathic, and the like ; or, again, according to the external form
Avhich they present, into the papular, vesicular, pustular, tubercular,
and squamous exudative dermatoses.

A. — Exudative Dermatoses of which the course is acute.

The affections which belong to this order may at once be further
subdivided into two groups, by the fact that certain among them are
invariably caused by contagion, and themselves also generate an
infectious principle, whereas the others neither owe their origin to
contagion nor develope it during their course.

142 GENERAL OBSERVATIONS.

A. — Acute, exudative, contagious Dermatoses.

The diseases of the skiu uow to be desciibed resemble one
another so decidedly in their symptoms, in their mode of develop-
ment and retrogression, in their tendency to run a typical course,
and in the sympathetic disturbance of the whole organism with which
they are accompanied, that they are regarded by many writers
(among whom are Alibert, l\ichs, Dietl, Upmau, and others) as
members of a distinct pathological family.

Now, I do not agree with the opinion that diseases in general are
capable of being arranged in natural families, hke minerals, plants,
animals, or other specimens. And yet I cannot but admit that there is,
in many respects, a most striking uniformity in the symptoms which
characterise the acute, contagious, exudative affections of the skin,
and that, at first sight, it appears tempting to regard theni as
standing in the same relation to one another as do the species which
make up a natural family. But, according to the views held
at the present day of the nature of pathological conditions, we must
altogether abandon ontology, and regard diseases as having no
existence sui generis, and as consistnig, not of individuals, but merely
of changes afiecting natural products, and occurring in individual
persons. Hence the principle of the natural system cannot be ap-
plied, with correctness, in the classification of cutaneous, any more
than of any other diseases.

And yet I am forced to adopt the fundamental idea of the natural
system in the classification of skin-affections, and particularly of
the exanthemata, as of all systems the most adapted for the easy
comprehension of these diseases, and as satisfying most fully the
practical requirements of both teacher and learner. This is, indeed,
seen in no class of diseases more prominently than in those now to
be described, which I group together under the name of exanthemata
;imr excellence. The attempt has indeed been made, both formerly
and within a recent period, to give to this term a more general meaning,
and to apply it to diseases which are chronic, as well as to those
which run an acute course. I am, however, of opinion, that it is
better to reserve for the group of affections with which we are now
immediately concerned a name which may be common to them all ;
and, for this purpose, I find no expression more suitable than the
word exanthem, I understand, tlien, by an exanthem, a disease toMch

ACUTE, EXUDATIVE, CONTAGIOUS DERMATOSES. 143

attach the whole organism, is aUenäecl lo'ith febrile symptoms, pre-
sents certain definite appearances upon the cutaneous surface, developes
a contagious principile, and, lastly, runs an acute course, the duration,
of which can he computed beforehand.

The common nature of the exanthemata is shown by the follow-
ing circumstances :

(i) They are all preceded by a febrile condition of the system,
varying in duration from a few hours to several days, according
to the intensity of the morbid process and the individual pecuhari-
ties of the patient.

(2) The appearances presented by the skin usually develope them-
selves in regular order, and in stages, the duration of which is
determinate, and capable of being predicted.

(3) The length of time durhag which the rash remams visible and
that occupied by its involution, are, both of them, definite, and per-
fectly well known.

(4) In all these diseases the sympathy of the entire organism
is manifested by symptoms of various kinds, both while the rash is
present and also after its disappearance.

(5) Lastly, each of these complaints, as a rule, attacks a person
only once in the course of his life.

It has long been the practice to divide into definite periods the
regular course which, as I have said, the exanthemata observe;
but writers have pleased themselves as regards the number of such
periods which they have admitted, some having been content
with two, others recognising as many as eleven. In my opinion,
the only true basis for the establishment of these periods (or stages,
as they are called) is an accurate observation of the course of each
disease; and it appears to me that, by admitting four such stages,
I shall most fully satisfy the requirements of the case.

Thus, I apply the term stadium prodromorum to the period which
elapses between the commencement of the malady and the first
decided appearance of the rash. During this stage the symptoms
are chiefly such as are generally called " febrile ;^'' but both the
mucous membranes and the nervous system are also commonly
disordered to a greater or less extent.

Next comes the stadium eruptionis, during which the efflorescence
developes itself. This does not at first present any characters from
which a diagnosis can be made, for, as is well known, measles,
scarlatina, and variola, are, in their earliest condition, very similar

14i GENERAL OBSERVATIONS.

to one another. The second stage^ indeed, continues only till the
marks, peculiar to some one of the exanthemata, make their ap-
pearance ; and as soon as one can assign to the disease its appropriate
name the stadium erujdionis ceases, and the third period, the
stadium floritiouis, begins.

This third stage embraces the whole time during which the rash
is at its height. Hence this stage has a diiferent duration in each of the
exanthemata, and it also varies in individual cases, according to the
extent and severity of the eruption. Thus, in slight forms of measles
or varicella this period may not last more than a few days ; whereas
it occupies several days, or even weeks, in the more severe varieties
of scarlatina and smallpox.

Tlie fourth stage, the stadium exsiccaiionis, desquamationis, sen
decnistationis, commences at the time when the morbid phenomena
peculiar to the exanthem begin to subside : that is, in morbilli and
scarlatina, when the redness disappears; in smallpox, when the
drying up of the pustules commences. As, however, the morbid
changes in the skin, due to the exauthematic process, vary greatly
in the different exanthemata, and also in each particular case (ac-
cording to the extent and severity of the disease), this stage, likewise,
is of uncertain duration, and must, in fact, be regarded as terminating
only when the health is fully established.

I consider it superfluous to establish either a stadium, finis seu
recoiivalescenVue, or a stadium acmes. This last-mentioned stage,
during which the rash is just at its height, has been admitted by many
observers; but its limits are to a great extent arbitrary, and its
recognition is attended with no practical advantage whatever. It
appears to me, also, that no detailed description is required of the
stage of incnhaiion or latency, between the moment of infection and
the beginning of the stadium prodromorumy for the simple reason
that, during this period, there are no symptoms of any kind to
indicate the presence of disease.

On the other hand, I think it useful, both to the learner and the
teacher, to distinguish, in each of the four periods I have named,
the symptoms resulting from the febrile state of the organism, from
those due to the implication of particular organs or systems, and
also from the morbid appearances presented- by the skin. We shall,
tlien, in each stage of the disease, take into consideration three
separate groups of symptoms — the fehrile, the concomitant, and the
exanthematic.

ACUTE, EXUDATIVE, NON-CONTAGIOUS DERMATOSES. 145

A further subdivision of the exanthemata, although not indispen-
sably necessary, can yet hardly be avoided. For, while scarlatina
and measles present merely a reddening of the skin, with small
papules, or (in exceptional cases) vesicles^ and have therefore been
termed the exanthemata glabra (Hildebrand), variola and vaccinia
are characterised by the simultaneous development of vesicles and
pustules, and are consequently named the exanthemata scabra.

B. — Äctite, exudative, but non-contagious Dermatoses}

The morbid changes in the skin, which I group together under
tliis a])pellation, have in common the following characters :

(i) The course of these diseases is acute, and they are of short
duration, although, in certain exceptional cases, they may be pro-
longed by the occurrence of relapses.

(2) The different symptoms succeed one another in regular
order ; in other words, each of these affections has a definite typical
course.

(3) No contagious principle is developed during their progress,
although they may in some instances (as, for example, in the case of
glanders) be generated by the transference of a poison from one of
the lower animals to man.

So far as their external appearance is concerned, these diseases
may naturally be divided into the following groups :

[a) Certain of them do not go beyond the formation of red
maculae, tubercles, or wheals. It is quite exceptional for these
affections, at any stage of their existence, to give rise to any other
form of efflorescence, although in the urticaria bullosa we have an
example of such an occurrence.

{b) In certain of them, again, the inflammatory character is pe-
culiarly prominent. The distinctions between these diseases are based
either on their causes alone, or on the extent to which the eruption
is diffused over the cutaneous surface, or, on the other hand, on its
being confined to some particular part, or affecting only certain
strata of the integument.

(c) Under this head are also comprised those diseases of the skin
characterised by the development of serous exudation beneath the
epidermis, so as to form vesicles or bullae.

' V. p. 196 of the origiual Germau.

146 GENERAL OBSERVATIONS.

Thus, then, the cutaneous affections which I place among the
acuie, exudaiive, non-contagious dermatoses^ are divided into the
three following groups :

I. The ^olt/morpJious erythemata (polymorphe Erytheme).
II. The dermatit'ides.
III. TJie 'ßldyctcBnoses.

I. — The Polpnorphous Erytliemata.

It is well known that the terms erythema and roseola were applied
by Willan, so as to comprise certain cutaneous affections cha-
racterised by reddening of the surface, and that this writer did not
take into consideration the question whether the rash in a particular
disease is caused by mere transitory hypersemia, or by a more or less
persistent vascularity of the part, attended with exudation into the
tissue of the skin. But it has been shown by clinical observation that
certain among these appearances are, in reality, thus transient, and
caused merely by slight vascular injection. Such fugitive rashes,
when spread over large parts of the surface, are termed erythemata;
but when they present isolated red maculae, of the size of a finger-nail,
they receive the name of roseola. In either case, however, they arc
to be regarded as mere symptoms, and not as independent diseases.

Hence I have thought it necessary to separate these from those
other erythemata and roseolcC which require to be looked at as dis-
tinct maladies, not only on account of their longer duration, but
also because they undergo successive metamorphoses, and are attended
by various symptoms, which show that the whole system is involved
in the disease ; and it seems to me that when I thus employ the names
erythema and roseola to designate affections which are not all of the
same kind, the fault lies not so much with me, as with Willan and
others, who have arbitrarily, and without distinction, applied these
terms to different forms of disease. It would have been easy for
me to coin new names for affections which come under this head;
but, having already had to point out that in dermatology the
vocabulary is even now too rich, and that there are, in fact, fewer
diseases of the skin than names for those diseases, I have thought it
more advisable to retain the old appellations. I shall, however, in
referring to the forms of erythema and roseola, due to exudative

POLYMORPHOUS ERYTHEMATA. 147

processes, add to each of these terms the epithet " exudative/' in
order to distinguish these affections from those previously spoken
of.^ The third disease, tiriicaria, inckided in the same group, of
course requires no such addition to its name.

The following is the general description of the polymorphous
erythemata. The rash present in these diseases consists either of red,
and for the most part distinct maculEe, or of raised, colourless papules,
tubercles, or wheals, or, again, of large elevated patches, formed by
their coalesence. These eruptions are never of long duration. Very
often they undergo no further changes, disappearing without giving
rise to any desquamation or to pigment-deposit ; but, in certahi cases,
they last somewhat longer, spread over the surface of the skin, present
various changes in their form, and, under such circumstances, are
generally followed, when the redness has subsided, by one of the
above-mentioned appearances. No concomitant or febrile symptoms
essentially belong to tliese diseases. Cases in which they run their
course without fever, and at no period cause any disturbance of the
health of the patient, are as frequent as those in which various febrile
or other symptoms are observed during the presence of the rash.
Under the head of polymorphous erythemata, I include the follow-
ing diseases :

1. Erythema exudativum.

{a) Erythema exudativum multiforme.
[b) Erythema nodosum.

2. Roseola exudativa.

3. Urticaria.

II. — The Bermatitides proper?

Uuder the name of inflammations of the sJcin, in the strictest
sense of the term, I group together a number of morbid conditions,
in which the ordinary signs of inflammation are present in the most
marked degree. These signs are, as is well known, redness, heat,
swelling, and pain (including itching and feelings of tension). The
nutrition of the part is also perverted, and,iu consequence, its functions

• V. pp. 4, 50, et seq.

' V. p. 215 of the original German.

1-18 GENERAL OBSEllVATlüNS.

are disturbed. The diseases to whicli I now refer arc also attended
with all those changes to whicli^ from the first;, the terms " results
of inflammation/' " products of inflammation/' have been applied,
and wliich were formerly regarded as the principal evidence of the
presence of an inflammatory process. Under these are included
exudations (whether fluid or solid), enlargement of the part (either
for a time or permanently), healthy or unhealthy suppuration, gan-
grene, &c.

I ajn not ignorant of the fact that there is among authors a wide
divergence of opinion with reference to the inflammatory affections
of the skin. Indeed, some writers (as, for exam])le, P. Eayer) include
almost all acute cutaneous diseases under the head of inflammation,
dividing this into the exantliematic, the simple, and the phleg-
monous ; while others (among whom is Fuchs) restrict within very
narrow limits the use of the word dermatitis, applying it only to
certain idiopathic processes, in which the symptoms of inflammation
are present in the most marked degree.

Now, I cannot express my concurrence in either of these views.
On the one hand, 1 do not regard the exanthemata as mere inflam-
matory affections, and certainly not as inflammations of the skin
alone, believing them to depend rather upon a toxic action, aff'ecting
the whole organism. This toxic action may accidentally produce
in the skin changes resembling those due to inflammation, but,
as is indeed well known, does not invariably give rise to any such
appearances. In fact, these diseases sometimes run through their
whole course, in a tolerably severe form, witliout localisation in
the skin, being then termed the variola, morbilli, scarlatina sine
exantliemale. So, again, the cutaneous affections which I have
grouped together under the name of the ]}olijriior2ihoiis erythemata,
are not inflammations of the skin in the stricter sense of the word,
because redness is almost the only symptom of inflammation which
they present ; and they also differ widely from the forms of dermatitis
proper, with which we are now concerned, not only in their course
(for, as a rule, no inflammatory products are thrown out in these
diseases), but also in the nature of the morbid changes in the skin
to which they give rise.

In spite of these reasons for distinguishing the exanthematic and
erythematous inflammations of the skin from the dermatitides proper,
I am, however, convinced that no absolute line of sejmration can be
drawn between them, and that many cases occur which can with

DERMATITIDES. 149

difficulty be made to accord with the distinctions laid down ; of
this we have an instance in the Uriicana lullosa. But I find some
consolation for this in the fact that it is not possible, in any one
of the natural history sciences, to carry out a systematic arrangement
with perfect strictness. Moreover, there are many other instances,
as, for example^ in cases of syphihs and scrofulosis, in which
morbid affections of the skin, although setting in wdth inflammatory
symptoms, are yet not classed among the dermatitides.

It remains to deal with the other view, of which T took Fuchs as
the representative. This writer will not even admit the inflammatory
character of erysipelas, but labours to prove that great differences,
exist between a simple inflammation of the skin (])hyma, dermatitis) ,
and erysipelas or furunculosis. This opinion, again, I am unable to
adopt, for I cannot find, in the appearances Avliich manifest them-
selves during these diseases, the distinctions on which Fuchs lays so
much stress. I think, too, that it would be difficult to prove that
erysipelas, in which redness, swelling, heat, &c. — in fact, all the
symptoms of inflammation — occur almost in a typical form, cannot
be an inflammation of the skin, because (in the opinion of this writer)
it is caused by disease of the digestive organs, and particularly of
the liver. Indeed, suppuration, ulceration, and gangrene — the
results of inflammation, as they are termed in the older medical
and surgical works — seldom come under the observation of the phy-
sician in so marked a form as in this disease, which (even in the
sense of the natural-historical school) cannot but be regarded as an
erysipelatous inflammation of the skin. It is also necessary to re-
member that in the dermatitides the morbid products do not always
bear the impress of their cause so plahily as to afford a basis sufficient
for the purposes of classification. For example, the yellow colour of
an exudation is not due to the admixture of biliary matter, as is
assumed by the natural-historical school of pathologists, in accordance
M'ith the views of Schönlein. This appearance in reality arises
merely from the presence of a small quantity of the colouring matter
of blood.

In saying this I do not, however, mean to assert that inflamma-
tions of the skin are due to local causes merely, and are to be
regarded as afiections of the integument alone. I, as well as
others, know that these diseases arise sometimes from injuries acting
directly upon the skin, sometimes from deleterious influences, de-
pendent either on certain peculiar animal poisons or on affections of

150 GENERAL OBSERVATIONS.

internal organs, or even of the whole system. We are, therefore,
completely justified in dividhig the inflammations of the skin into
the idiopathic and the symptomatic. But, nevertheless, it must not
be forgotten that, in either case, the characters of inflammation are
present, and that the appearances by no means differ so decidedly
as to form in themselves a sufficient basis for diagnosis or for classi-
fication. Hence I adopt, for these purposes, the anatomical subdi-
visions given by my colleague Rokitansky,^ and distinguish the
inflammations of the skin according to their seat, and the course
which they run, into the erythematous and the phlegmonous. Of
these two forms, the first affects merely the superficial layers of the
cutis, and principally the papilla?, while the second involves the whole
thickness of the skin, as well as the subcutaneous connective tissue.

These varieties of dermatitis may be distinguished from each other
both in the dead body and during life ; and therefore the recognition
of them as separate forms of disease is quite in accordance with the
requirements of clinical observation.

The symptoms of the erijthematous inflammation of the skin consist
in a rose- or blood-red coloration, disappearing under pressure, and
in a slight degree of swelling, caused by serous exudation or oedema.
In this affection the tension of the skin is inconsiderable, and little
or no pain or itching is complained of. Its course is always acute,
and its chief peculiarity is that it generally terminates in the absorp-
tion of the inflammatory products, followed by deposit of pigment
or by desquamation of the cuticle. It rarely happens that either
vesicles, bulla), or pustules, develope themselves in this form of der-
matitis ; and there is never any deeply seated suppuration, attended
with loss of substance, or followed by the formation of cicatrices.

In the phlegmonous inflammations of the skin, on the other hand,
the swelling is more considerable, ajid the redness is more intense,
seldom disappearing entirely beneath the pressure of the finger.
The inflamed parts of the skin are also indurated to an extreme
degree throughout their whole extent ; this being due to the infil-
tration of the cutis, and also of the subcutaneous tissue, with sohd
exudation-matter, and of course giving rise to great tension and
severe pain. The phlegmonous forms of inflammation of the skin
are always attended with healthy or unhealthy suppuration or with
sloughing.

* 'Lehrbuch der pathologischeu Anatomie,' 3te umgearbeitete Auflage,
Wien, 1855, Baud ii, p., 59.

DERMATITIDES. 151

It is obvious that, in tlie case of an organ offering so
large a surface as the skin, the extent to which an inflammatory
affection spreads must be a very important character, and must
necessarily modify the other symptoms. Hence it is needful to draw
attention to the fact that both the erythematous and the phleg-
monous forms of inflammation of the skin are sometimes circum-
scribed and confined to a limited area, sometimes diffused and spread
over large tracts of skin ; indeed, looking at them from this point
of view, we might divide these affections also into a Dermatitis
circumscripta and a D. diffusa.

Both Rokitansky and I have, moreover, classified the inflammations
of the skin on a third basis, according to the nature of their cause,
separating, in fact, the idiopathic from the symptomatic forms of
these affections. Tor in practice we have frequent occasion to dis-
tinguish the varieties of dermatitis produced by local influences (such
as wounds, toxic agents, heat or cold) from those whicli are of un-
known origin, or the effect of some general disease. This division
is, indeed, not only legitimate, but, from a clinical point of view,
particularly useful. But we must not trust entirely to the appear-
ances observed on the skin, in endeavouring to determine, in a
particular instance, whether the affection is idiopathic or symptomatic.
In this, as in all other cases, we have to take all the symptoms fnto
account, and must endeavour to refer to their true source each one of
the phenomena which simultaneously present themselves.

For the reasons just stated, I have adopted the last-mentioned
characters as the basis of my classification of the dermatitides, dis-
tinguishing them into the idiopathic and symptomatic. Under each
of these heads I have also made further subdivisions, according to
the anatomical characters of the disease (whether erythematous or
phlegmonous), and also according to its distribution (whether cir-
cumscribed or diffuse).

Tabular vietv 0/ the various Jorms of Dermatitis,
A. — Dermatitis Idiopath ica.

ßfa. cncumscripta. ) ^^ ^^^^^-^^^

[_b. diffusa.

a. erythematosa. ( 7. .■,• m

11 Dermatitis Traumatica.

phieffmonosa. -r^

^ ° / ,, f efienata.

152 GENERAL OBSERVATIONS.

B. — Dermatitis Symptomatica.

a. erythematosa Erysipelas.

h. phlegmonosa

[a) circumscripta . . Fimmculus, Antlirax.

ijj) diffusa .... Pseudo-erysipelas.

III. — The 'PMijctcEuoses}

Under this term I include those acute exudative diseases of the
skin, of which one of the characteristic appearances is the accumu-
lation of fluid beneath the epidermis, so as to form vesicles or bulla?.
These present, in different cases, very varied forms, and may be
grouped in different Avays. They always, however, subside sponta-
neously within a short time, and their duration may be predicted
with considerable accuracy. Some of these diseases have no liability
whatever to return, and those M'hich sometimes recur do so only
after the lapse of a considerable time, so that the complaint may
then be looked at as a fresh attack rather than as a rela2:)se, in the
proper sense of tlie word. They, therefore, differ essentially from
those vesicular affections, such as eczema, in which recurrence is the
rule.

I shall have to enumerate under the head of Phlyctsenoses the
following maladies :

1. Herpes.

2. Miliaria.

3. Ponphigns acutus.

B. — Exudative Dermatoses which run a chronic course.^

In this group I include all those diseases of the skin which, having
their origin in those disturbances of nutrition termed the exudative
or inflammatory processes, and presenting in general the symptoms
already described as characteristic of those processes, yet differ from the
other affections belonging to this class in their tendency to repeated

' Fide p. 248 of the original German.
- Vide p. 270 of the original German.

CHRONIC EXUDATIVE DERMATOSES. 153

relapse?, and, consequently, in the protracted course which they run.
The chronic exudative dermatoses are distinguished from one another
chiefly by dilTercnces in the cutaneous eruptions present in these
diseases. Indeed, they are, for the most part, attended with wo febrile
or concomitant symptoms, and therefore our attention is directed
principally to the so-called exanthematic symptoms which they
present.

In arranging systematically the skin- affections which come under
this head, one has recourse, involuntarily, to the classification of
Plenck and Willan, which will indeed, in my opinion, always be
pre-eminently adapted for this purpose. But I think it desirable
to modify this system, so far as to base the distinctive characters
of the different groups of eruptions upon several, or rather upon
all the symptoms present, and not upon only one of them, the
accidental ^jrimary efflorescence. In the first group, then, which I
shall term the squamous chronic dermatoses, I shall include not only
certain skin-affections, namely, psoriasis and pityriasis, which were
described by Willan under the same title, but also those forms of
lic//en which I have as yet had occasion to observe. Hence I define
this group as consisting of those cutaneous diseases which manifest
themselves by a superficial redness and slight swelling, affecting
principally the papillae of the cutis ; which are attended with an ex-
cessive growth of the epidermis (Epidermidalwucherung), but only
with very trifling sensations of itching, tension, or pain ; and, lastly,
in which the inflammatory products never break down, ulcerate,
suppurate, liquefy, or, indeed, undergo any further metamorphosis
whatever.

The chronic exudative skin-affections which are allied most closely
to the first group, and naturally come next in order, are those which
are attended with intense itching, and which I therefore term the
pruriginous dermatoses. The common feature of these diseases is,
then (besides the characteristic efflorescence which they present),
the fact that they irresistibly provoke scratching in consequence of
the severe itching by which they are accompanied. This, again,
gives rise mechanically, or as a result of the irritation produced by it,
to those further changes in the surface of the skin which are known
under the name of excoriations, and which form a concomitant
symptom, never absent in the pruriginous dermatoses.

The most important distinctive character between the different
cutaneous diseases belonging to this group, is the fact that one of

154 GENERAL OBSERVATIONS.

them (eczema) is attended with a more or less profuse excretion
of morbid products, which ooze from the skin's surface, whereas no
such appearance is observed in the others (prurigo and scabies).

The third group embraces those tubercular and pustular affections
which arise from inflammation of the hair-sacs and sebaceous glands.
These I term the pimply (finnenartig) dermatoses. They have
always been recognised as forms of acne, and are, as is well known,
distinguished into an acne vulgaris seu disseminata, an acne mentagra
or sycosis, and an acne rosacea. These skin-complaints are charac-
terised, not only by their peculiar appearance, but also by their in-
variably affecting some particular region of the body.

The fourth group includes those affections which consist in the accu-
mulation of pus beneath the cuticle, or, in other words, in the forma-
tion of sub-epidermidal abscesses or ][mstules. jS^ow, there are but
few diseases of the skin in the course of which pustular eruptions
may not present themselves. The pustules are then, however, for
the most part, merely accessory appearances, unless, indeed, they
are developed from papules, vesicles, tubercles, or bullae, previously
under observation. But in the affections belonging to the group
of which I am now speaking, the pustules are seen from the first,
and constitute the whole eruption. In accordance with the nomen-
clature of Willan, I shall treat of these cutaneous diseases under
the names of impetigo and eclJipna.

The fifth group, lastly, will embrace those chronic affections of
the skin which are distinguished by the formation of bullae, the
epidermis being raised by the exudation of fluid in large quantity
beneath it. The form of these eruptions is so characteristic that all
detailed description of them in this place seems to be unnecessary.
I apply to them the usual name oi jiempJdgiis.

I shall, then, describe the chronic exudative dermatoses according
to the following scheme :

Group I. — Dermatoses Squamosa. Squamous dermatoses.

1 . Psoriasis seu Lepra Willani.

2. Lichen exudativns.

a. ruber.

b. scrofulosorum.

3. Pityriasis rubra.

CHRONIC EXUDATIVE DERMATOSES. 155

Group II. — Dermatoses Pruriginosa. Prurigiuous dermatoses.

1. Eczema.

a. squamosum = Pityriasis rubra,
i. papulosum seu lichenoides.

c. vesiculosxim = Eczema solare Willani.

d. ruhrum seu madidans.

e. m])etiginosum seu crustosum..

2. Scabies.

3. Prurigo.

Group III. — Dermatoses Acneifornm. Acnciform dermatoses.

1. Acne vulgaris seic disseminata.

2. Sj/cosis seu acne mentagra.

3. Ac7ie rosacea.

Group IV. — Dermatoses Pustulosce. Pustular dermatoses.

I. Impetigo.
1. Ecthyma.

Group Y. — Dermatoses Pemphigosce. Pempliigous dermatoses.

1. Pemphigus chronicus.

a. pemphigus vulgaris.

b. „ foliaceus.

2. Rupia.

CHAPTER YIII.

MORBILLI, MEASLES.i
(CLASS IV.— ACUTE, EXUDATIVE, CONTAGIOUS DERMATOSES.)

Er THE LATE De. FRAXZ MAYR,
k. k. peofessoe of p^diateik in the st. anna hospital foe childeen

at vienna.

Retised by Peof. IIEBRA.

The word morhilli is derived from the Italian morllllo, which
moans the Utile disease. Measles received this name to distinguish
it from the plague, which was then known as il morho.

It cannot be positively proved, from the works of either the Greek
or the Eoman writers, that this complaint existed in ancient times.
Ehazes was probably the first to introduce a knowledge of it into
Europe : but long after his time it was confounded with miliaria and
scarlatina.

The merit of having shown measles to be altogether distinct from
scarlatina must be ascribed to Porestus and Sydenham, the former
of whom gave an account of an epidemic of measles which occurred
in Brabant in 1580, while the latter described one which prevailed
in London from the year 1664 to 1670.

The now abundant literature of this subject does not date further
back than the last century. It has been collected in as complete a
form as possible by J. Frank and Canstatt.^ The following writings,
however, deserve to be specially mentioned: — Jlei/f elder ('Schmidt's
Jahrbücher,' 1835, Band viii, p. 105). Gerfsema, Marcus Busch

1 This chapter is translated in full from the German edition, except that,
with the sanction of Prof. Hebra, most, of the details with reference to the
compücatious and sequelai of measles have been omitted; it being thought
that a lengthy description of these affections hardly comes.within the province
of a work on cutaneous diseases. — [Ed.]

^ 'Jahresbericht,' Rand ii, p. 107.

MORBILLI (mAYR). 157

{' Spccimeu Med. Inaug. de Affinitate Morbillorum cum Scarlatina/
Gröiiingise, 1844)- Tilgen, Henricus Gulielmus ('De Siraili-
tudiiie et Dissiinilitudine Scarlatinse, Morbillorum, Rubeolarum, et
Typhi/ Bonn, 1 844) . Rilliet {' Memoire sur TEpidemie de rougeole
qui a regne a Geneve dans le premier mois de Tan 1847^).
John Broion ("On the Epidemic Measles of 1854 in Leith/^
'Edinburgh Monthly Journal of Medicine/ 1855, vol. xx, pp. 299,

SymptoTM.

Definition. — The disease known as morhilU or measles (Eubeola,
Masern, Elccken, Rougeole) is characterised by an eruption consist-
ing of maculae or papules, distinct from one another, and scattered
over the whole cutaneous surface. It is accompanied with fever,
and with a catarrhal affection of the respiratory mucous membrane.
It runs an acute course, and spreads by contagion.

It was laid down by Ililliet and by Chomel that the so-called
period of latency or incubation, between the infection of the
organism with measles and the appearance of the eruption, has a
duration of about a week.

These observers did not, however, institute any direct experiments
for the purpose of deciding tliis point; but their statements have
since been fully confirmed by the results of inoculating other indi-
viduals with either the blood or the nasal mucus of patients affected
with this disease. In this way it has been ascertained that the
period of latency occupies at least eight days, and may even, in
certain cases, last as long as three weeks. During this time the
infected person appears perfectly well, or may occasionally experience
an uncomfortable feeling, which is, however, of an indefinite charac-
ter, resembling sometimes fatigue, sometimes nausea, or some kind
of painful sensation. In certain cases the pulse is slightly accele-
rated towards the end of this period ; but this does not give rise to
any serious consequences.

I. Stadium Prodromorum.

Febrile Si/mptoms. — These present no special peculiarities from
which one could, with certainty, infer that the eruption of measles is
about to make its appearance. Hence the expressiony^^;-?'* morhil-

158 MORBILLI (MAYR).

losa, if used in this sense, is incorrect. The phenomena observed
during this period are, in fact, the ordinary and well-known symptoms
of fever — alternating sensations of cold and heat, pains in the joints,
prostration, headache, and dryness of the skin. Their intensity is
greatest in the evening.

Concomitant Sj/mptoms. — The existence of an inflammatory affec-
tion of the conjunctiva and the respiratory mucous membrane is
more decisive as to the nature of the complaint than the presence
of fever.

The interior of the nose seems to be the original seat of this catar-
rhal inflammation, which spreads thence to the conjunctiva, as well
as to the larynx and trachea, without always affecting the mouth or
fauces. This affords an explanation of certain of the symptoms of
measles — such as the sneezing, the discharge of mucus from the
nose, the feelings of weight over the forehead and eyebrows, the
oftentimes repeated epistaxis, the punctated reddening of the carun-
cula lachrymalis and conjuctiva generally, and, lastly, the lachryma-
tion and intolerance of light {Ophthahniamorhillosd). The affection
of the mucous membrane of the trachea is generally indicated by a
hollow cough, quite dry or attended with but slight mucous expec-
toration, by a feeling of oppression beneath the sternum, and, some-
times, by a tickling or burning sensation in the throat. It is true
that these symptoms likewise accompany other catarrhal complaints ;
but in measles they spread and increase in severity so rapidly that,
even while the exanthem is still latent, we can often predict, almost
with certainty, that it is about to break out. This is particularly the
case during the prevalence of an e])idemic of morbilli.

Exanthematic spnjdums. — These are, of course, altogether wanting
during this stage.

Duration. — This period usually lasts from three to five days, but
may seem to be much shorter, because the first shght affection of
the nasal mucous membrane often appears some days before any
other symptom, and may then entirely escape observation. In this
case it is only when the more severe catarrhal symptoms, attended
Avith fever, set in that the presence of the disease is noticed. On the
other liand, in persons previously in ill health, and particularly in
those who are rachitic, tuberculous, or scrofulous, this stage may be
prolonged to a remarkable extent, so as even to last as long as ten
days.

SYMPTOMS. ]59

II. Stadium Eruptionis.

Fehrile symptoms. — The fever gradually increases in intensity, as
is shown by the pulse becoming more and more quick, so that it
may even beat 140 times in the minute. Convulsions and other
head symptoms often arise in children, and a turgescence (Turgescenz)
of the skin is observed, the surface of the body being also, in most
cases, dry. As a rule, this period commences on the thirteenth day
after infection with the disease.

Concomitant symiüoms. — Those present during the previous
stage acquire an increased severity, but, generally speaking, no fresh
ones make their appearance. Andral states that he has found the
intensity of the concomitant symptoms to be in an inverse ratio with
the amount of the eruption in those cases in which there is already
great depression of the strength, or in which some affection of the
respiratory organs has set in even during this stage. Isolated
symptoms of cerebral or nervous disturbance, however alarming
they may appear, are in reality, even in children, less to be dreaded
during this period of measles, than in scarlatina or smallpox.

Exanthematic symptoms. — The eruption appears first on the
temples and back of the neck, afterwards spreading forwards over
the swollen face and the forehead, downwards to the throat and
the upper part of the chest, and backwards over the neck and
the upper dorsal region.

It consists of distinct maculae or minute red points (Pünktchen),
raised above the surface, and often to be detected by the touch
rather than the sight. At this time the rash cannot in any way
be distinguished from a commencing smallpox efflorescence. Within
twenty-four hours, however, the maculae and papules become con-
siderably larger, and are, therefore, more plainly visible ; and the
deep red colour of the eruption, its distribution over large tracts of
the surface, and its uniform character, then enable us to make a
positive diagnosis of the nature of the disease.

Tlie rash of morbiili is of the precise colour which is obtained
by adding a little yellow or brown to a red pigment.

160 MORBILLI (MAYR).

III. Stadium Florltlonis.

Febrile Symptoms. — These generally increase in proportion as the
development of the efflorescence advances, and diminish as it
subsides.

Concomitant symptotns. — The various affections above mentioned
now gradually disappear : the intolerance of light ceases ; the punc-
tated redness of the conjunctiva is no longer to be observed; the
lachrymation subsides ; the secretion of the nasal mucous membrane
becomes more viscid and of a yellowish colour ; the cough is less
frequent, and is attended with the expulsion of a thick yellow matter
Sputa blennorrhoica), \\\\\c\\ forms large masses of jagged outline
(wie gezackt), and bears, according to Chomel, a very close resem-
blance to the sputa of phthisical patients. It is, however, more
probable that this kind of expectoration arises from a croupous
inflammation of the mucous membrane of the trachea and bronchial
tubes.

Ex-anthematic symptoms. — At the time when the rasli is at its
height the maculae are as large as hemp-seeds, or even beans. These
spots are, however, formed by the coalescence of several smaller ones
which were at first distinct, whereas the papules (in that form of the
disease known under the name of viorbilli pajmlosi) remain still
isolated from one another. The maculae have sometimes an irregular
or jagged outline, Avhich often presents peculiar semicircular curves.
The skin between them is always of the natural colour; tliere is no
tendency in measles, as there is in the different forms of erythema,
for the maculae to enlarge, and spread over the adjacent parts of tlie
cutaneous surface. In exceptional cases, and principally in newly
born infants, the rash of morbilli is made up of fine red points.

Having thus developed itself, the efflorescence next spreads in
regular succession over the upper limbs, abdomen, back, genitals,
and loins ; and, last of all, appears on the lower extremities. It does
not altogether spare even the palms of the hands or the soles of the
feet.

The rash of measles, then, extends to more remote parts, accord-
ing to their distance from its original seat; and experience does not

SYMPTOMS. 161

altogether confirm the statement of those writers who describe it as
affecting the different parts of the body in the same order as small-
pox. The rapidity of its diffusion is in direct proportion to the
youth of the patient, but it is generally completed by the end of the
third day. Soon afterwards, that is, early on the fourth day, it
begins to subside. Except that it fades more quickly on exposed
parts of the surface than on those which are covered with clothes,
its disappearance takes place in the same order as its development.
The skin does not resume its natural appearance as soon as the rash
has subsided ; the seat of each red macule or papule being always
occupied for a time by a spot or a papule containing pigment -
deposit. The depth of the colour thus produced varies with the
severity of the disease and the intensity of the previous efflorescence,
but we can, even at this period, recognise the nature of the com-
])laint by the uniform distribution of these spots of pigment over
the whole cutaneous surface.

This exanthem does not attack the mucous membranes in the
same way as the skin. If the morbid process is very intense, a
plastic exudation may indeed be formed upon the mucous surfaces.
But, generally speaking, the extension of the complaint to these
structures is shown only by their secreting action being increased.
This is observed, during life, chiefly in the case of the palpebral
conjunctiva ; but in the dead body it may be shown that the lining
membrane of the nose and that of the air-passages are similarly
affected.

IV. Stadium Desquamationis.

Febrile sunqüoms. — When the disease runs its ordinary course
these are altogether wanting.

Concomitant sj/nijHoms. — The affections of the mucous membranes
observed while the rash is present have now, in most cases, altogether
disappeared, or at least give rise to scarcely any symptoms. Those
who maintain that there is an enantliematic as well as an exanthematic
process lay stress on the fact that the disease is followed by a des-
quamation of the epithelium of the mucous membranes affected by
it. There is, however, nothing peculiar in this occurrence, which
is observed after catarrhal complaints of every kind. Indeed, no
increase in the amount of epithelium contained in the urine or f&eces

16.2 ' MORBILLI (MAYR).

is to be detected so long as these excretions remain normal, wliich;
in measleSj is usually the case.

Mxaathemalic symjiioms, — During this period the cuticle becomes
detached in the form of branny scales, which make their appearance
first on the exposed regions of the body, that is, on the face,
neck, and hands. They are observed most distinctly on certain
parts of the face (such as the temples, the sides of the nose, and the
chin) and on the neck, the upper half of the chest and forearms.
In other regions there may be scarcely any discoverable desquama-
tion, or even none at all, particularly if the skin is constantly in a
state of profuse perspiration. The separation of the scales is not
generally completed till after the fourteenth day, reckoned from
the first appearance of the efflorescence.

Irregular Forms of Measles.

This disease does not always follow the typical course m hieb I
have been hitherto describing. Indeed, many cases, especially in
children, are met with in which there are irregularities in the length
of the different stages, or modifications of various kinds in the symp-
toms. For example, even in healthy persons the period of incubation
is often prolonged to two or three weeks without our being able to
assign any cause for this occurrence. The same thing happens still
more frequently when the individual is already the subject of dis-
ease, and particularly in children allected with some neurosis, or with
anaemia or rachitis. Again, in patients suft'ering from any of these
complaints the Stadium jjrodromoriim may be lengthened so as to
last a week or even ten days, the period of latency being, in this
case, of normal duration; and, in exceptional instances, either of
the other stages may be protracted in a similar way. Hence, the
modifications of morbilli evidently require to be described in detail,
and for this purpose I shall arrange them as follows : —

I. Varieties in the Localisatioji of the Rash.

The way in which the eruption of measles spreads, affecting in
regular succession different parts of the cutaneous surface, is one of
the most constant, and for the purposes of diagnosis one of the most
essential characters of this disease. But it doea -occasionally happen
that, instead of appearing on the face, the rash is first seen on some

IRREGULAR FORMS. 163

distant part of the bodj. Tlius^ if the patient has been lying for
some time on one side it may commence on that arm ; if ointments,
plasters or lotions have been applied to the chest, it may present
itself first in that region ; if any part of a limb is compressed by tight
bandages or articles of clothing, the efflorescence may make its
appearance at that spot.

In other instances, again, in which this eruption affects the
different parts of the body in regular order, it is very imperfectly
developed. Thus, its presence may be confined to the face and
trunk, no trace of it being seen on the limbs. This is observed
chiefly in cases of spinal disease {Sjjondßarthrocaee) , in which the
rash is often altogether, or, at any rate, very nearly, absent on the
paralysed lower extremities.

In some cases of measles, too, independently of the presence
of any other disease, the efflorescence is almost limited to the face
and neck, the maculae being so sparingly distributed over other parts
of the body that one could count them without much trouble.
This variety of the rash is observed chiefly when an epidemic is
either beginning or just about to subside.

2. Tarieties in the Duration of the Stadium Flontionis.

In severe epidemics of Morbilli attended with intense catarrhal
symptoms, it is not uncommon to find the efflorescence remaining
visible during a week or even ten days. In such cases, however, it
usually undergoes certain changes in character, the original yellowish
or brownish-red colour passing into a bluish or dark brown tint, which
no longer fades beneath the pressure of the finger. These spots of
pigment are not infrequently observed in patients suffering from
some other eruption, such as eczema, lichen, scabies or pityriasis.
But if the skin was previously health}^, these macule must
be regarded as being due to the presence of some severe internal
disease.

A symptom which, not without reason, excites alarm, is the
premature disappearance, or sudden fading, of the effioresceuce.
This arises from some internal malady, rather thaii from any
external influence, and therefore its cause must always be carefully
investigated.

It has been supposed that in these cases the eruption recedes
from the cutaneous surface, and undergoes metastasis to more im*

164 MORBILLI (MAYR).

portant parts. But this belief is not supported by a close examina-
tion of the facts. Por, before the rash fades or disappears, the
internal disease is always present — a proof that this disease is the
cause, and not the effect, of the disappearance of the rash. The
opinion generally held is the very opposite of this ; the visceral
affection being, by most writers, ascribed to the exanthematic
eruption alone of all the symptoms of measles. In these cases, as
the internal or general complaint subsides, the maculae not un-
frequently reappear. But it must not be supposed that a fresh
eruption is formed under these circumstances ; the return of tlie
efflorescence is due merely to the renewal of the former hypersemic
condition of the skin.

According to Willan and Peter Trank, a second eruption some-
times appears in cases of measles, when desquamation is com-
mencing. This affection, however, ought probably to be regarded as
a Eoseola, such as is not rarely observed in little children in whom
the skin is delicate. It is not generally attended with any febrile
symptoms, and its occurrence is a matter of no importance.

3. Prolongation of the period of Besqiiarnaiion.

This is generally caused by some protracted sequela of measles.
Rubbing fatty substances into the skin may appear to interfere Avith
the process of desquamation, and to diminish its amount, but does
not in reahty produce these effects.

4. MorliUi Apyretici.

The non-febrile variety of measles is the mildest form of the
disease. It cannot indeed be said, that any cases of morbilli are
absolutely " sine felre" but the existence of fever may certainly be
indicated only by the occurrence of slight evening exacerbations, by
a trifling acceleration of the pulse, and by the existence of sliglit
malaise and depression. This form of measles is observed chiefly
during the early part of an epidemic.

5. Fehris MorhiUosa sine exanthemaie.

This may be stated to be a " Felris catarrMsa " of the nasal,
tracheal, or bronchial mucous membrane, appearing during an

IRREGULAR FORMS. 165

epidemic of measles, and in persons who have been exposed to the
contagion of this disease.

The assertion that this modification of measles is followed by
desquamation of the cuticle, is most certainly incorrect. For unless
the skin has previously been in a hypersemic state, or the subject of
an exudative process, there is no reason why the epidermis should be
shed in an unusual degree. Hence the actual occurrence of conse-
cutive desquamation in such a case must be explained by sup-
posing that a slight rash did exist, but was overlooked.

6. Varieties in the appearance of the Rash.

W& recognise the following modifications in the form of the
eruption of measles :

I. Morbilli laves. — This is the form above described, in which
the efflorescence is smooth and flat, the hair-sacs not being much
raised above the cutaneous surface. The individual maculte, too,
are distinctly separated from one another by tracts of healthy skin,
It is the most common form of measles, and is the only one observed
in certain epidemics.

3. Morhilli papulosi. — In this variety of the disease, there appear
dark red or reddish-brown points (Stippen), or papules, the size of
millet or hemp seeds, containing pigment, and seated at the mouths
of the hair-follicles. In such cases the rash presents the greatest
possible resemblance to that of smallpox, and its real nature can be
recognised only by its uniform distribution over the cutaneous sur-
face, and by the greater amount of pigment contained in the
papules. This form of measles, again, occurs chiefly in certain
epidemics, taking the place of the more usual variety. The Nirlus
(Nirles) of Alibert (the "Blattermasern" of Bloest^s translation)
must also be placed here, being most probably nothing more than a
papular form of measles.

3. Morbilli vesiculosi sen miliares {Frieselmasern) . In this variety
the mouths of the hair-sacs, being filled with fluid exudation, become
raised, and form delicate, transparent, miliary vesicles. This gives
the skin a peculiar aspect, resembling that observed in 3J Hi aria.
Indeed, it is probable that the peculiarities of the efflorescence in
these cases are in part produced by the same causes, to which we
attribute the formation of the vesicles of miliaria, being due either to
profuse sweating or to pysemic conditions. To this form of measles
we ought perhaps to ascribe the epidemics of miliaria, which have

166 MORBILLI (mAYR).

been described by certain writers, but are at the present day no
longer met with.

4. Morbilli conferti seu conßuentes. — In this variety of the erup-
tion the maculae are crowded together, or even confluent. This is,
of course, the result of the formation of maculse or papules in such
large numbers that the intervals between them are reduced to
nothing, or exist only when the rash first comes out. In fact,
there subsequently appear continuous red patches, of considerable
extent, but strictly circumscribed, and with deeply indented margins.
These patches are observed chiefly on the face, back, and upper and
lower limbs. Even in cases of this kind, however, the real nature
of the disease may invariably be made out, for we can always find
some spots at which the efflorescejice is of the ordinary kind, and
co7isists of distinct maculae. I believe that even in the youngest
infants the eruption of measles never covers, uninterruptedly, the
w hole cutaneous surface.

To this form of morbilli is probably to be ascribed the "Exanthema
hi/hrldiun," described by Schönlein, and named by him ntheola. It
is stated that in this disease a scarlatinal rash is associated with the
concomitant symptoms of measles.

(5) Morbilli hcemorrliagici. — In this variety the efflorescence
consists of maculfe or papules which are of a dark red colour, and
do not disappear beneath the pressure of the finger. This peculiarity
of the rash is the result of hsemorrhage from the capillary blood-
vessels of the skin.

7. Varieties consisting i?i lite combination of otlier^ chronic or acutem
skin affections with the Bash of Measles.

The presence of a chronic cutaneous disease by no means renders
a person unsusceptible of the contagion of measles. Tor instance,
children affected with vesicular or pustular eruptions are just as
liable to this complaint as those in whom the skin is perfectly
liealthy.

Under these circumstances the pre-existing skin affection recedes
for a time while the exanthem is going through its stages. More-
over, when the fever ceases, the desquamation is, in these cases,
unusually abundant. It has, indeed, been maintained by some that
this necessarily removes the previous disease. But this statement is
incorrect, for after the subsidence of the measles the clironic erup-
tion generally reappears with even greater intensity than before.

COMPLICATIONS. 167

As for the combination of morbilli uitli tlie otlier exanthemata,
variola and scarlatina, I have never had the good fortune to see two
of these diseases shnultaneousljj in the same patient. Indeed, apart
from the fact that such a diagnosis is in itself attended with very
great difficulties, another (and a much more natural) explanation
suggests itself in all these cases. Thus, in the instances said to
have been observed by Fouquier, Chomel, Moret, and others, of the
eo-existence of measles with smallpox, the eruption was most likely
a Boseola variolosa. Again, the supposed combination of scarlatina
and morbilli was probably very similar in appearance to the Scarlatina
variegaia. Two of the exanthemata, however, not unfrequently
attack, in succession, the same individual; and this is observed
especially in districts which contain persons aftected with each of
the diseases in question.

A few bullse or wheals are not uncommonly jn'esent in cases of
measles in addition to the maculae. This, however, does not give
rise to any difficulty in diagnosis.

It sometimes happens that a general erythema is associated witli the
morbillous efBorescence. This, however, is quite an ephemeral con-
dition, and probably arises from the patient, during a severe epidemic,
being kept too warm. It is always easy to determine the real nature
of such an affection, from its irregular mode of development and of
involution, and from its arising at any period of the disease, being
unattended with febrile disturbance, and not spreading completely
over the whole cutaneous surface.

This form of erythema often appears in patches on the chest and
abdomen, and also on the upper and lower limbs, and after remain-
ing one or two days disappears without having perceptibly modified
the pre-existing exanthem or leaving behind it any effects whatever.
The rubeola Sclionleinii (the hybrid exanthem resembling scarlatina,
to which I have already referred) is probably sometimes merely
a rash of this kind, appearing during the stadium floriiionis of
measles. This supposition is the more reasonable because, as is
admitted even by the supporters of SchÖnlein's views, this eruption
is never epidemic, being observed only in a sporadic form.

8. Coinplications of Measles.

This exanthem is said to be complicated when any one of the
various concomitant symptoms observed during its regular course
becomes so severe, or so extensively diffused, as to constitute

108 ' MORBILLI (MAYR).

au iudepeucleut affection. The complications thus produced may
very greatly modify the development of measles, or delay, or even
entirely stop, the progress of the disease.

The cause of these complications must be sought either (i) in
the individual peculiarities of the patient, or (2) in the conditions
under -which he lives, or (3) in the special characters of the
epidemic which prevails at the time.

(i) Persons who present an unhealthy soil for the reception of
the morbillous contagion not merely pass through the ordinary
exanthematic process, but are at the same time attacked by other
affections. This is particularly the case in patients who arc
liable to inflammatory diseases of the larynx, trachea, or lungs. The
same thing, too, is observed in individuals who are (as it is termed)
tuberculous or scrofulous, even though before the measles appeared
this condition may have been so little marked that we could
scarcely term it more than a tnorhid tendency.

(2) Under this head must be mentioned, that careless or un-
skilful nursing, closeness or dampness of situation, overcrowding or
imperfect ventilation of hospital wards, may bethe cause of various
complications which do not make their appearance when patients
are placed under more favorable conditions.

(3) As I shall hereafter more fully explain, each epidemic of
this disease presents its own peculiarities. Thus, whereas in-
flammatory affections are sometimes very common complications of
measles, there is, in other years, a special prevalence of gangrene
and dissolution of the blood (Blutzersetzung).

The affections which are liable to complicate measles may be
divided into two groups ; the first consisting of diseases of the
respiratory organs, the second including those of other parts of
the body and of the blood.

Certain writers have simply described this exanthem as presenting
an inflammatori/, a nervous, and a putrid form. But it appears to
me that this arrangement is a bad one, not only because it is of too
general a kind, but also because it looks to the character of the fever
rather than to the nature of the morbid state to which this character
is due, and because such a view would lead one to suppose that
different species of fever may be present in morbilli. I think that
the classification I have proposed is more practical, and that it
accords better with the divisions suggested by the actual observation
of cases which have taken an abnormal course.

COMPLICATIONS. 169

J. Among the complications wliicli form tlie first group are the
following :

(i) Epistaxls, or hemorrhage from the nasal mucous membrane.
This is the result of an extreme hypersemia^ and in some cases, and
particularly in infants, is so severe as to be dangerous. It appears
chiefly during the stadium prodromonm, but may occur after the
exanthem has developed itself ; in which case it sometimes causes the
rash to fade, but only when there has been a considerable loss of
blood. It is, in some instances, to be regarded as the result of a
general dissolution of the blood.

(2) Ophthalmia. — The so-called " morlillous ophthalmia " in
reality differs in no way from a common catarrhal inflammation. It
may present itself in any stage of measles, either as a simple con-
junctivitis, as a severe inflammatory swelling of the raucous mem-
brane and submucous connective tissue, as a pustular affection, or
even, though more rarely, as a keratitis. The most common of
these is the purulent ophthalmia (Ophthalmoblenorrhoen). Every
epidemic of morbilli presents at least scattered instances of this
affection, which occurs especially in weakly children, and is most
destructive to the organ of vision. This complication does not in
any way modify the morbillous rash.

A croupous inflammation of the conjunctiva has been observed in
certain cases of measles. The exudation covers the lining membrane
of the eyelids in the form of streaks or patches, and is of a whitish-
gray or yellowish colour, and firmly adherent. When intentionally
detached, it is quickly renewed. This affection is attended vrith
considerable oedema of the eyelids, and with severe pain. Its
course is always acute, and it often leads to perforation of the
cornea.

(3) Laryngitis. — Among the symptoms frequently observed
during the stadium prodromorum of measles is a hoarseness so com-
plete, that the patient can scarcely utter any audible sound. There
is, at the same time, a marked exacerbation of the fever; but the
breathing remains unaffected, and on physical examination we do
not find that the disease has extended to tlie bronchial tubes or
lungs. The complaint is, in fact, simply of a catarrhal nature ; but
it often passes into —

(4) Laryngitis croiiposa sen diphtheritica (Croup, Maserncroup) .
This complication may arise cither before the morbillous eruption
makes its appearance, or during its decline.

170 MORBILLI (^[AYR).

(a) When it occurs during the stadium, ■j}Toäi'omoruid, croup is
far less severe than when it presents itself at a later period of the
disease. Indeed, it is commonly spoken of as being merely ''false
croup ;" and the name of Laryngitis would be still more applicable
to it, for it has nothing in common with true croup except the
peculiar tone of the cough. However, in the early stage of measles
the varieties in the sound produced by the act of coughing pass so
gradually into one another, that it is difficult to draw a clear line of
distinction between the catarrhal, the spasmodic, and the croupy
forms of cough.

This laryngeal affection subsides, for the most part, as soon as the
rash breaks out. It may, indeed, last somewhat longer if it imme-
diately preceded the development of the eruption ; but even then it
disappears as soon as this has spread over the Avhole surface of the
body, and the fever begins to decline. As is generally the case,
however, slight hoarseness remains, and severe attacks of coughing
are still attended with more or less of the peculiar sound, throughout
the whole course of the patient^s illness.

Most of these cases, then, belong to that group of the so-called
croupous affections, in which the disease results from a catarrhal
inflammation of the nasal or tracheal mucous membrane, exciting
a severe laryngitis. This complaint, and that which sets in suddenly
with the formation of plastic exudation, differ both in the course
which they take, and hi the degree of intensity of their symptoms.

Again, in the early stage of measles we rarely see either that form
of croup which is due to the propagation of an inflammatory affec-
tion from the fauces to the epiglottis and glottis, or that which
appears as a complication of a croupous pneumonia and bronchitis.
I do not mean to say that dm-ing this period of the disease a
diphtheritic laryngitis is never observed ; but its occurrence is
certainly exceptional.

{!)) Croup setting in after the morbillous rash has made its
appearance is a much more dangerous complication, and very often
leads to a fatal issue. It generally arises on the second or third
day of the eruption, and therefore on about the sixth day of the
disease, but sometimes not till desquamation has commenced. It is
often preceded by a pneumonia or an extensive bronchitis ; while, in
other instances, it arises from an aphthous or diphtheritic inflam-
mation of the mouth and fauces.

The distinction between tlie two forms of croup of which I have

COMPLICATIONS. 171

been speaking is shown most clearly by post-mortem examinations.
For when this complication appears in the early stage of measles,
death occurs either from bronchitis, pneumonia, or pulmonary
oedema, and no plastic exudation is to be discovered in the larynx ;
whereas in the second form of this complaint croupous inflamma-
tory products are found in the lungs and bronchial tubes, and the
larynx contains a yellowish viscid mucus, or even a diphtheritic
deposit.

Moreover, granular and membranous forms of exudation are met
with in some cases, though more rarely. They generally result
from the extension of a diphtheritic affection from the mouth and
fauces to the glottis. In other instances, however, this so-called
secondary croup arises from an inflammation of the lungs or bronchial
tubes ; we may therefore say that it sometimes ascends, sometimes
descends.

The variety of croup consequent upon diphtheritis of the mouth
and fauces affects chiefly children suffering from tubercular disease
of the glands, but is in most cases immediately caused by some epi-
demic influence of an unknown kind. Hence its occurrence is the
rule in some epidemics of measles, the exception in others.

The affections of which I have been speaking do not all interfere
to the same extent with the progress of the exanthem. Indeed, the
false croup in no way modifies either the development or the further
course of the eruption. On the other hand, various changes in the
appearance of the efflorescence are produced when the disease is
complicated by an attack of true croup. In some cases the maculae
remain in the condition which they had reached when the severe
symptoms of internal disease first showed themselves, but gradually
lose their red colour and form brown pigmented spots, which no
longer disappear beneath the pressure of the finger, and may even be
visible after death. In other instances the rash disappears alto-
gether, and the skin assumes a livid hue. Sometimes, lastly, the
maculfe coalesce in some places into patches as large as the hand ;
but when the more severe exacerbations of fever arise, the eruption
in these cases disappears altogether, and there arises a partial des-
quamation of the cuticle.

(5) Inflammation of the Trachea and Bronchial Tales. — This, again,
appears \w two forms, the catarrhal and the croupous, — the former of
these being the more common, the latter the more obstinate variety.

These affections arc comparatively seldom observed in adults, or.

172 MORBILLI (MAYR).

at any rate, do not in them present sufficient intensity to be dan-
gerous to life. Indeed, as fatal complications, they are met with
chiefly in infants less than a year old, who are are ill-fed, or the
subjects of rachitis or atrophy. In larger and stronger children,
however, they are often the precursors of pneumonia or laryngeal
croup, and soon pass into one or other of these diseases.

The occurrence of an attack of bronchitis, in either the catarrhal
or the croupous form, modifies to a certain extent the course of the
eruption of measles. The maculiB, which are in these cases originally
much less distinct than usual, at once disappear, leaving behind
them, however, in rachitic children, spots of pigment-deposit,

(6) Inßammation of the Lungs. — Pneumonia is the most frequent
complication of morbilli. Indeed, the cases in which it is present
were at one time recognised as a variety of the disease, under
the name of Morbilli ivßammaforii. IN'ow it appears to me impor-
tant to distinguish between the lobar and the lobular form of
inflammation of the lungs accompanying measles. Lobar pneu-
monia may arise either at the commencement of the catarrhal
fever or when the disease is at its height, being in the latter case
the result of the extension of inflammatory action from the bron-
chial tubes to the air-vesicles. Its onset is sometimes sudden and
violent, as in cases of ordinary inflammation of the lungs ; sometimes
(and particularly in weakly, and scrofulous or rachitic children) so
insidious, that its presence cannot be discovered without a physical
examination of the chest.

The lobular form of pneumonia, on the other hand, is more often
consecutive to, than a complication of, measles ; and even when it
does arise during the course of this disease, it persists long after the
termination of the exanthem, and forms one of the most obstinate of
its sequelse ; among which, therefore, I shall again have to speak of
this affection.

The course of morbilli is modified by inflammation of the lungs
more than by any other disease of the respiratory organs. The
effects of this complication are, indeed, similar to those above de-
scribed as produced by bronchitis, except that pneumonia is a more
severe complaint, and that the rash, therefore, retrocedes more
rapidly. When the fever accompanying this affection first sets in,
however, the intensity of the efflorescence becomes for a time greater
than before ; but as the inflammatory symptoms increase the erup-
tion quickly fades, so that very soon no trace of it is to be seen. It

COMPLICATIONS. 173

was this fact which gave rise to the erroneous belief that the efflo-
rescence in these cases undergoes " repercussion " (Zurücktreten) or
"metastasis." I have, however, already shown, when describing
the ansemise of the skin, that the disappearance of the rash under
these circumstances is in reality to be ascribed to the bloodless con-
dition of the|cutis, and not to any metastasis of a morbid product
deposited in the cutaneous tissues. In cases of little severity the
maculae may either become the seat of pigmentary deposit, or simply
remain in the same state in which the pneumonia found them.

(7) Tassis convulsiva, seu Pertussis. — This affection often oc-
curs as a complication of morbilli, and it is still more frequently
observed to follow epidemics of that disease. Indeed, these two
complaints ate so closely related to one another, that cases of
whooping-cough present themselves in every great epidemic of
measles, either preceding the exanthem or arising during its course.
This peculiar afiinity seems to be due to the fact that the mucous
membrane of the respiratory organs is the seat of each of these
diseases (dass beide Krankheiten im System der Schleimhaut der
Respirationsorgane ihren Sitz haben) .

Whether, in any particular case, whooping-cough shall be sus-
pended by an attack of measles or shall co-exist with this exanthem,
depends on the extent to which the air-passages are involved. If
no severe bronchitis or lobular pneumonia is associated with the
pertussis, its course will be arrested by the eruptive fever, and it
will remain latent till this subsides. But if these inflammatory
affections are present, the supervention of morbilli will in no way in-
terfere with the whooping-cough. Hence, in its early stages, or even
when it has reached its greatest intensity, this affection is very often
interrupted or removed by measles. But during the later periods
of whooping-cough, when fever is present, such a thing rarely occurs ;
the two diseases then go on simultaneously. These facts were often
observed during the epidemics of morbiUi which occurred at Vienna
in 1846 and 1848.

B. The complications belonging to the second group are affections
of the organism in general, due to morbid conditions of the blood
or of some of the solid tissues. They are the following : —

(i) Scorbutus. — This is one of the less dangerous complications of
morbilli, particularly when the nutrition of the body is not impaired.
The morbid state of the gums and the hseraorrhagic spots in the

174 MORBILLI (MAYR).

skin (Sjiilosis scorbutica) are the symptoms of scurvy most com-
monly observed in cases of measles, haemoptysis being more rarely
present. The petechia may either occupy the same spots as the
morbillous rash, or affect hkewise the intervening spaces. They last
three or four days, and disappear at the same time as the pigmented
maculae of the exanthem. It is certainly natural to fear that cases
of this kind should have a fatal issue ; but such a termination is
nevertheless seldom observed in comparison with its frequency in
the hpemorrhagic form of smallpox.

(2) Gangrene. — Various parts of the body may be attacked by
gangrene as a result of measles. Affections of this kind, however,
generally arise when the fever has subsided ; and even if they are
associated with some complaint developed during the febrile stage of
the disease, they do not in any way modify the exanthem, and there-
fore are in reality sequela of measles, under which head I shall
again mention them. The only form of gangrene which is, properly
speaking, a complication of morbilli, is that which affects the lungs.
Happily, however, this is of very rare occurrence, aj^pearing chiefly
in overcrowded localities, and only when other gangrenous diseases
are prevalent.

(3) Dissolution of the Blood. — (Morbillöse Blutdissolutiou,
Nervöse Morbillen, Morbillentyphus.) — The term "Morbillen-
typhus " was a correct one so long as a state of stupefaction was
regarded as the main symptom of typhus, according to the ety-
mology of the word. But now that the characters of typhus are better
known, and that post-mortem appearances of a different kind have
been associated with it, the expression Morbillentyphus is no longer
admissible. Hence I prefer to speak of the condition with which
we are now concerned as a '' dissolution of the blood ;" a name
which is also applicable to the similar affections observed in the
course of the other exanthemata.

The following symptoms accompany this morbid state of the
blood in cases of measles : — There is severe depression from the
very commencement of the disease. The fever is continuous, and
increases day by day. The pulse is at first hard,, but soon becomes
compressible, and the artery has then an empty feel. The skin is
sometimes hot and dry, sometimes cool and covered Avitli profuse
perspiration. There is intense thirst. The general muscular weak-
ness and depression of the nervous system are extreme, and no local
disease can be discovered to which these sym])toms coidd be attvi-

COMPLICATIONS. 175

buted. The patient is apathetic, and is sometimes drowsy, some-
times delirious. The mucous membrane of the mouth is of a dirty-
red colour; the tongue dry, and covered with a white fur; the lips
also are dry, and are often loaded with black sordes. The abdoine]i
is distended and in a state of meteorismus, and tender on pressure ;
but there is not more pain in the right hypochondrium than in other
regions.

In these cases the morbillous rash does not present the usual red
colour, but is bluish, and soon fades, generally leaving behind it a
deposit of reddish-brown pigment.

This form of measles takes a rapid course, and is seldom prolonged
beyond a week. These cases rarely terminate in convalescence, and
only after a protracted illness.

It much more often happens that these cases end fatally, and
become the subject of post-mortem examinations. The blood is
then sometimes found to be fluid, and of a cherry-red or brownisli-
red colour ; while in other instances it is viscid and tarry. It is
accumulated in the internal organs, such as the brain, the lower
lobes of the lungs, and the heart, spleen, and liver. All the viscera
are remarkably soft and flacid. There is, moreover, in some cases,
enlargement of the spleen ; and the mesenteric glands also are some-
times infiltrated, as in typhus (enteric) fever.

(4) Acute Tuberculosis. — This most commonly takes the form of
miliary tubercle, and is incontestably one of the worst complications
of measles. It appears especially in certain epidemics, and was, for
instance, observed with great frequency in that which prevailed in
A'^iemia in January, 1853.

The symptoms of tuberculosis arising during an attack of mor-
billi are, in children, almost exclusively those of acute hydro-
cephalus. The onset of this affection is generally sudden, and its
course is violent and very rapid, terminating within a week or a
fortnight. The invasion of this disease often interrupts the
development of the exanthem, or checks its subsequent progress
and soon causes it to entirely disappear. A few erythematous
maculse sometimes show themselves in the place of the morbillous
rash.

In these cases the recent granulations are found most frequently
in the pia mater and arachnoid, the lungs, and the peritoneum
covering the spleen and liver. But as these deposits are always
associated with the presence of tuberculous matter of older date, it

176 MORBILLI (mate).

appears probable that the exanthem does not generate the tubercu-
losis de novo, but merely calls it into active existence.

Diagnosis of Morbilli.

There are certain diseases which, in some cases, at any rate in par-
ticular stages of their course, resemble measles so closely that they
may be mistaken for it. These are smallpox, scarlatina, miliaria
rubra, and roseola.

The most common error of diagnosis, and the one most easily
committed, is between morbilli and variola. Each of these com-
plaints is, in fact, attended with catarrhal symptoms, though not
usually in the same degree of intensity. In each of them, again,
the rash appears first upon the face in the form of minute red points,
distinct from one another, and spreads to other parts of the body
in the anatomical order. It is, therefore, easy to understand that
on the third or fourth day of the disease (reckoned from tlie begin-
ning of the febrile symptoms) it may often be impossible to deter-
mine positively whether or not a case is one of measles.

Under these circumstances, no conclusive evidence is to be ob-
tained as to the nature of the complaint, and therefore the diagnosis
must remain uncertain till the question is decided by the progressive
development of the papules into vesicles (if it be variola), or by the
rash remaining in the form of maculse or papules (if it be morbilli).

The differential diagnosis of measles from Scarlatina and Bliliaria
rubra will be given in the description of those affections.

As for roseola, there is no difference between it and the smooth
variety of morbilli so far as the form and colour of the maculsc are
concerned. Nevertheless, the only cases in which there is a diffi-
culty in distinguishing between these affections are those which
occur in newly born infants, of roseola covering the whole surface of
the body. And, even then, there are sufficient grounds for making
a diagnosis. For the catarrhal symptoms of measles are absent;
no fever precedes or accompanies the rash, nor does this occupy any
definite locality, nor spread in regular order from the face over the
rest of the body. Lastly, roseola presents no contagious properties,
and does not occur epidemically.

PATHOLOGICAL ANATOMY. 177

Pathological Anatom ij of Measles.

Amoug the pathological changes produced by this disease must
be mentioned, in the first place, a catarrhal inflammation of the
mucous membrane of the respiratory tract ; an inflammation which,
however, does not diff'er in its results from ordinary catarrhal affec-
tions; The nasal mucus secreted in these cases is at first trans-
parent, afterwards opaque. It always presents an alkaline, never au
acid reaction.

It remains for future researches in pathological chemistry to
show in what way the circulating fluid is altered by morbilli. In
most fatal cases the blood is found after death to be of a bluish or
brownish-red colour, and is seldom completely coagulated. It is
sometimes thick and tarry^ sometimes thin^ and of a cherry-red
tint.

The efflorescence consists essentially in the pouring out of exuda-
tion round the mouths of the hair-sacs. These consequently become
raised above the level of the skin, forming minute papules, or even
vesicles, if the apertures of the canals should happen to be closed. At
the same time, there is a superficial injection of the surrounding part of
the integument ; but this, being generally limited by the cutaneous
furrows, does not present the appearance of an inflammatory halo.
The larger maculte are formed by the coalescence of smaller ones.
G. Simon states, as the result of his investigations, that the epi-
dermis is still in immediate contact with the corium, but is slightly
swollen at those points where papules exist. This observer found
no change in the hair-sacs or sebaceous glands, nor even iu the
cutaneous papillae.

SequeUc of Measles.

Under this head I include those complaints which, though result'
ing from the disease, nevertheless arise after its termination, and con-
tinue as independent affections; so that they are caused by the
exanthem, and yet cannot be said to modify in any way its develop-
ment or its course. I do not regard as sequelce of morbilli disorders
which are merely accidentally associated with it.

178 MORBILLI (MAYR).

These complaints are to be regarded as the effects of conditions
which existed before the outbreak of the measles. Such are various
morbid states of the body, and particularly tuberculosis, scrofulosis,
rachitis, and chlorosis ; and also other circumstances prejudicial to
the health of the patient, such as his having suffered from certain
diseases, or living in a damp house, or (in the case of children) having
been neglected or fed improperly. The exanthem itself is often
accused of producing these sequelae ; but although this may be true
of local diseases, it is, according to my experience, never so of those
which affect the body generally. For, whatever treatment may have
been adoj^ted, and even if the complaint has been allowed to run its
course without interference, I have never seen it give rise to any
consecutive affection the germs of which did not exist before the
patient was attacked by the morbilli.

The following are the principal sequelae of measles :
' (i) Ozaua caiarrhalis. — This appears not only in children
evidently scrofulous at the time of the attack of morbilli, but also
ill those who had for years presented no sigu of such a morbid
tendency.

(2) Chronic Ophthalmia. — This complaint sometimes takes the
form of a pustular affection, and sometimes ajipcars as an inflamma-
tion of the Meibomian glands {eczema, seu achor c'diornni). The
latter is a very obstinate complaint, and during winter is frequently
observed after measles, affecting principally poor people who dwell
in close, damp houses.

(3) Chronic Inflammation of the Lart/n.v, Trachea, and Bronchial
Tuhes.

(4) Lobular Pneumonia. — This is the most common of all the
sequelae of morbilli, being met with in every epidemic of this disease.

As I mentioned when speaking of the complications of this ex^
anthem, lobular pneumonia is often present at the time when the
rash first breaks out ; but even in this case it is always prolonged
far beyond the ordinary duration of morbilli. In some cases, on the
other hand, it sets in towards the end of the attack, or even some
Aveeks later still. This sequela is observed principally in children
who are between two and six years old, and affected with some
scrofulous or tubercular complaint.

Chronic Tuberculosis. — During epidemics of morbilli, we have
only too frequent occasion to observe that this .exanthem is often
followed by chronic tubercular disease of the lungs ; and we know

SEQUELiE. 179

that this is especially liable to occur in the case of persons who had
suffered from some scrofulous affection before they were attacked by
the measles, or in whom the lymphatic glands, or the lungs them-
selves, were already the seat of scattered tubercular deposits
(tuberculose, phthisische Anlage), even though these may have given
rise to no marked symptoms.

In the present state of our knowledge, therefore, it does not seem
likely that it is the exanthem which in these cases first sows the
seeds of pulmonary phthisis. It is much more probable that bron-
diitis or pneumonia sometimes, when protracted, leads to the deposi-
tion of tubercular matter, and that in other instances phthisical
affections, hitherto latent, become aggravated by subsequent attacks
of bronchitis, so that new deposits of gray granulations take place,
and set up a progressive form of chronic pulmonary disease. Tlius
it is rare for measles to pass directly into phthisis by the transfor-
mation into tubercle of pneumonic exudation recently deposited in the
pulmonary tissue. In the majority of cases the exanthem merely gives
rise to an inflammatory affection of the lungs, and thus calls into
activity germs which were present before, although they produced
no symptoms. There is no peculiarity whatever in the course of the
tubercular diseases consecutive to measles, nor in their post-mortem
appearances.

(6) Di^phtheritic Affections of the mucous membrane of the
mouth, or, in young girls, of the labia pudenda.

(7) Gangrene. — This is, fortunately, one of the rarer sequelae of
measles. It may attack the walls of the buccal cavity, the female
genital organs, or even, though less frequently, other parts of the
body. These affections sometimes commence during the stadium
floritlonis, but more frequently not till desquamation is going on.
Experience teaches that their occurrence is favoured by the presence
of certain local affections, or of any of the complications of the
original disease.

]N[ext to the mouth and female genital organs, the parts of the
body most liable to be attacked by gangrene after measles are the
following : the external auditory passage, in cases in which an
otorrhcea eczematosa has existed ; the pinna of the ear, if eczematous
excoriations were previously present ; the alse nasi, in scrofulous
children. But it may arise at any spot affected with ulceration,
or with some cutaneous disease.

These various forms of gangrene, however, are by no means so

180 MORBILLI (MAYU).

closely connected with the exanthem as the two varieties first
mentioned.

These, then, are the most common of the complaints which, fol-
lowing measles, stand in a causal relation to that disease. These
sequelee differ essentially from those which merely occur accidentally
after the exanthem has run its course (as, for instance, ague,
dropsies, and neuralgic complaints), or which arise from a subse-
quent infection by some other coiitagious disorder, such as typhus,
scarlatina, or smallpox.

Frof/nosh of Measles.

The course and termination of this disease vary greatly, according
as it is simple or attended with complications and sequelae.

In general, it may be said that epidemics of morbilli are of a less
malignant character than those of scarlet fever or variola.

The course taken by any individual case of measles depends in
part upon the nature of the epidemic, in part upon the 2)revious state
of the patient's health.

The following are the conditions which, as a rule, justify us in
hoping that a case of morbilli will terminate favorably : — The fever
should be moderate, except during the evening exacerbations ; the
pulse not exceeding 120 beats in the minute, and the temperature
being below 100° T. : moreover, both temperature and pulse should
begin to fall as soon as the rash is fully out, and should afterwards
decline steadily. The skin onght to be moist ; there should be no
disi)roportion between the amount of fever and the degree of mus-
cular debility ; the breathing, even if cjuickened, should yet be deep,
and should give rise to no particular pain; the cough should be
slight and loose, and should subside as soon as the efflorescence dis-
appears. This, again, should be of the usual colour and of normal
duration, lasting not more than three days. Lastly, a good pro-
gnosis is to be given only when the patient is not very young, being,
at any rate, more than one year old.

The symptoms which are to be looked on as unfavorable are the
following : — Great weakness or excitement when the fever first sets
in ; the skin dry and hot ; the pulse hard and very rapid ; the re-
spiration laboured, much quickened, and attended with a short
cough. It is also a bad sign when the rash fades, or becomes of a
different colour, or disappears before the proper time; or, on the

ETIOLOGY. 181

other hand, wheu it remains longer than usual. This disease is
most fatal in persons who are ill nourished, and in those who are
rachitic, tuberculous or scrofulous, and particularly in children less
than a year old.

There are also certain special symptoms which should, lead us to
prognosticate an unfavorable termination. Among these are the
following : viz., profuse epistaxis ; croup, but only when it appears
between the fifth and the seventh day of the disease, when the rash
is fully out — for this complication is generally free from danger
Avhen it occurs at the commencement of an attack of measles ; tra-
cheitis or bronchitis, if intense, and principally in rachitic children ;
pneumonia, whether lobar or lobular, especially in young subjects ;
and, lastly, scorbutus, which generally adds greatly to the duration
of the disease. A fatal termination occurs in almost every case
complicated with gangrene, tuberculosis, or the so-called morbillous
dissolution of the blood.

Among the sequelse, the chronic forms of ophthalmia, tracheitis,
and bronchitis are remarkable, particularly in scrofulous subjects,
for their obstinacy and their tendency to relapse.

Etiology of Measles.

It is not in our power to produce the contagious principle of
morbilli in a visible or tangible form ; but experience has repeatedly
shown that a single case may infect whole families, and even dis-
tricts ; and this surely is sufficient to refute the opinion of those
who ascribe measles to an atmospheric or telluric influence of an
unknown kind. To prove that this disease is contagious, I have no
need to refer to the epidemics which have raged in remote islands,
M'here it has been most fatal to the natives, although occurring only
when introduced by strangers. In our own country, and under tlie
conditions in which we ourselves live, we have abundant oppor-
tunities of observing instances in which a perfect pestilence has
been generated by the presence of morbilli in one member of a
family, or by the admission of a single case of it among the patients
in an infirmary or a workhouse, or, above all, an hospital for children.

The secretions of the resphatory raucous membrane appear to be
the ordinary vehicle of the infectious principle of measles. But that
the blood also may convey it has been sliown by the experiments of

182 MORBILLI (MAYK).

Home (1757), Speraiiza (1812), and Katona (1842), each of whom
performed inoculations with that fluid. However, inoculations with
blood made by myself (Mayr) in 1848 and 1853 afforded negative
results.

The cutaneous perspiration^ too, ought perhaps to be included
among the bearers of the contagion of this disease.

In proof of these statements I may mention the following facts.

When children affected with measles have associated with others
during the stadinm proclromorum, before the rash has come out, they
have communicated the disease to their companions, even though
they were removed as soon as the first trace of the efftorescence
made its appearance. The complaint has broken out about a fort-
night afterwards in those who have been thus infected by it.

In September, 1851, a boy who was all'ected with well-marked
catarrhal symptoms, but presented no rash, was taken by his parents
to a place two miles distant from A'ienna. At this place no case of
morbilli had, up to that time, occurred. They remained there one day
only, during which the boy came into contact with another child, four
years old, belonging to some relations. On the second day after his
return to Vienna, the eruption of measles came out in the first-
mentioned boy ; and a fortnight later the other child, two miles off,
was attacked by the same complaint.

This case suggested to me (Mayr) the idea of proving that the
nasal mucus is capable of propagating measles by transferring this
substance to other individuals. I therefore performed this experi-
ment on two healthy children, living at a distance from one another,
at a time when the disease had ceased to be epidemic. Some nasal
mucus, taken from a patient during the stail'mmfloritionls of morbilli
and kept fluid by preserving it in a glass tube, was the same day placed
upon the mucous membrane of each of these children. In one of them
the first symptoms of sneezing appeared after eight days ; in the
other, at the end of nine days ; and, two days later, febrile symptoms
set in. In each child the rash made its appearance on the thirteenth
day after infection ; the disease was mild and ran its regular course.

I have also tried to propagate measles by transferring to other
children portions of epidermis shed during the stadium desqiiama-
tionis : my experiments, however, failed. This accords with the
statements previously made by .'Uexander !Monro ; but there liave,
nevertheless, been frequent disputes as to the correctness of the
opinion that the disease cannot be communicated in this way.

ETIOLOGY. 183

In this respect, then, the products of the desquamative process
in measles differ altogether from the crusts of variola ; for these, as
is well known, possess contagious properties.

We are, therefore, in a position to assert positively that morbilli
cannot be communicated by clothes, linen, or anything of a similar
kind, unless transferred immediately from one individual to another.
Again, no third ])erson, sucli as a medical man or an attendant, can
convey the disease, unless, indeed, he has stayed for a long time in
an atmosphere saturated witli the contagion, and very soon after-
wards, without having been much in the open air, comes into
contact with others who are susceptible of the disease.

From the facts stated above, it follows, too, that it is useless to
carry out the measure generally adopted when this exanthem attacks
some of the members of a family, of separati)ig from the others
those in whom the disease has shown itself. For when once the
catarrhal symptoms have made their appearance in even one chikl,
the danger of infection cannot be avoided (ist gegeben). A proof
of this is afforded by the rapidity with which this complaint spreads
among boys and girls who attend school or church together, or
live in the same estabhshment. We often hear surprise expressed
that one child after another should be attacked by measles, al-
though the greatest care is taken that none of those in whom the
rash has shown itself should come into contact with their school-
fellows until after the completion of the process of desquamation.
But tlie mistake lies in not commencing to separate them at th
time when the catarrhal symptoms first set in.

Every one is susceptible of the contagion of this exanthem. During
severe epidemics, adults who have hitherto escaped it are attacked
as Avell as children. Indeed, the general immunity of grown-up
persons is simply due to the facts, that in the densely inhabited parts
of Europe most people take measles while they are between two and
eight years old, and that, as a rule, this disease does not appear twice
in the same individual. It is, however, seldom observed in infants
immediately after birth, or while they are at the breast ; and very old
people also are rarely attacked by it.

I am unable, from my own experience, to confirm the state-
ments of Girtanner, Yogcl, and Guersant, that infants are some-
times affected with measles even before they come into tie
world.

Pregnancy affords no protection against morbilli, nor does the

18 i MORBILLI (MAYR).

existence of some other disease (whetlier cholera, typhus, variola,
scarlatina, or an inflammation of the brain, intestinal canal, or one
of the serous membranes) prevent the patient catching measles.
The rash, however, does not come out so loiig as any one of these
complaints is present, but appears only when it has subsided.
Hence this exanthem is frequently observed in the course of con-
valescence from some other acute disease, when the patient during
his first illness had been in contact with persons suffering from
morbilli.

Children affected with any chronic complaint, particularly if
it be of a scrofulous nature, are very susceptible of the contagion of
measles. This is especially the case with those who suffer from some
disease of the respiratory mucous membrane, such as pertussis,
bronchitis, or tuberculosis : on the other hand, an unusual power of
resisting infection belongs to children affected with ejiilepsy, chorea,
or paralysis.

The susceptibihty of morbilli is, as a rule, exhausted by a single
attack of the disease. But in exceptional cases, when this exanthem
is epidemic, we find adults affected with it for the second time,
having already passed through it during childhood. In fact, the
degree of immunity after measles is probably much the same as after
smallpox.

A change of residence, or of the accustomed conditions of life,
may afford fresh opportunities of catching this complaint, or indeed
any other of the acute exanthemata.

AVe are not as yet acquainted with any means of removing the
susceptibility of measles, even for a time, or while the disease is
epidemic. Camphor and sulphur have been vaunted as prophy-
lactics; but experiments made with them have yielded negative
results. There is no great advantage in transferring morbilli
directly from one individual to another, in the way described above,
for this simply reproduces the original complaint without any
diminution in its intensity ; nor does this procedure at all lessen the
probability of the occurrence of complications or sequelae.

I have still a few remarks to make with reference to the prevalence
of this disease in an epidemic form.

According to my present experience, minor epidemics of measles
occur about every three or four years ; more severe ones, at intervals
of eight or ten years. They may present themselves at any season,
but are more common during autumn and winter than during spring

TREATMENT. 183

and summer. They attack the inhabitants of populous towns more
severely than the rural population.

There is a definite relation between the severity of the onset of an
epidemic of morbilli and its duration^ this being in general short in
proportion as the epidemic was at first intense. The so-called epidemic
character of the disease depends not upon any specific malignant or
benign quality of the contagious principle, but upon a number of
different circumstances, among which are the weather, the season of
the year, and the nature of the other diseases which happen to be
prevalent at the time, or have recently been epidemic. Thus the
so-called seplic, gastric, or torpid (torpide) character of certain epi-
demics of measles is undoubtedly to be attributed to some one or
other of the conditions I have just mentioned.

Another circumstance concerned in giving a malignant character
to an epidemic of this disease, is the length of time which has
elapsed since it last prevailed. The more frequently epidemics occur
at any particular place, the milder their course ; whereas experience
has shown that this exanthem assumes its most unfavorable form in
regions where it had never before existed, or had, at any rate, not
been observed for a long time. This is the case, for instance, in the
Taröe Islands, Madeira, and St. Helena; and still more among the
North American Indians.

The complaints which have been most frequently observed as pre-
cursors of an epidemic of morbilli, are inflammatory affections of the
respiratory organs, influenza, and pertussis. Again, there is no
disease which follows such epidemics so commonly as Avhooping-
cough, which may thus be regarded as standing in a peculiarly close
relation to measles. This exanthem is, in fact, never very generally
prevalent without being associated with it, either as a precursor, a
complication, or a sequela.

Epidemics of morbilli occur in hot climates as well as within the
temj^erate zone ; but in very cold regions they seem to be less com-
mon, and, accordingly, to take a more unfavorable course.

Treatment of Morlilli.

The treatment of a case of uncomplicated measles should be based
upon the rule, that the natural course of the disease is not to be dis-
turbed by medicines of which the action is uncertain.

We know of no remedy which can ensure a favorable issue to this

186 MORBILLI (mAYR).

complaint. This is, indeed, shown by comparing cases which have
run their course without interference, with those treated according
to the different systems of the past, or even of more recent times.
Whatever plan is adopted, the result is probably much the same. It
is, however, well to avoid giving diaphoretic or alterative medicines :
these drugs do not in any way aid the exanthem when it runs its
natural course ; and they may favour the occurrence of complications,
which they certainly have no power to prevent.

The physician, then, has only to regulate the external conditions
under which the patient is placed, so that the complaint may go
through its stages favorably. For instance, quiet must be enjoined,
and while the fever lasts the temperature must be nniform ; but the
patient is not to be kept in bed longer than is necessary, and should
be lightly covered, and not buried in pillows. Indeed, children, to
whom lying in bed is peculiarly irksome, may, if well wrapped up,
be carried about the room. The temperature of the sick-chamber
should not be above 64° or 66° F., and fresh air should be f^dmitted
at least once daily. A very bright light may be injurious if there
is severe ophthalmia, but not otherwise.

The patient may be allowed to drink cold spring water, even while
fever is present. Emulsions and infusions which are heating or
oppress the stomach are not to be recommended.

When the disease is mild, and has reached the second or third
period of its course, the inclinations of the patient may, withiu
certain limits, be taken as 'our guide in the matter of nourishment,
especially in the case of children. For instance, broth and milk
may be given alternately. Even while the fever continues, the skin
must be kept clean. Articles of linen which have become soiled or
wet should at once be removed, and replaced by clean ones, first
thoroughly aired. The patient's face, or even the rest of the body,
if dirty, may be washed with tepid water; and if the skin is intensely
hot and "dry, great relief is given to the patient by ablution with
cold water, or inunction with some fatty substance.

When the fever and cough have become moderate or have alto-
gether subsided, the patient's strength Avill be restored by nourishing
food sooner than by tonic medicines.

After the termination of measles, — that is to say, after the four-
teenth day, — convalescence is favoured by the use of tepid baths,
either alone or in conjunction with cold ablutions,.. It was formerly
the rule, and is unhaj)])ily still sometimes the practice, to confine the

TREATMENT. " 187

patient to the house for a fixed period of a mouth or six weeks.
This, however, is not only unnecessary, but may even be injurious to a
weakly person, by depriving liini, for the time, of Avholesome and
refreshing air. Though often spoken of as a source of danger in
measles, '' catching cold '^ is in reality very seldom the cause of any
ill effects. Por experience shows that the offspring of poor parents
pass favorably through this disease, although placed under the worst
conditions and exposed to the most severe weather ; while, on the
other hand, children kept constantly in bed are particularly suscep-
tible of catarrhal complaints, not only because of the increjised
delicacy and liability to take cold which are thus artificially produced,
but also because the duration of the disease is much longer under
these circumstances.

The treatment of the complications of morbilli should be directed
solely and entirely against them. We must not allow the fact that
the patient is passing through an exanthem to prevent our pre-
scribing the appropriate remedies.

As for the sequelas, we have always to bear in mind that these
afi^ections are often the result of scrofulosis, tuberculosis, anoemia, or
the want of proper nourishment. The employment of the internal
medicines indicated by the existence of one of these conditions will,
however, be rendered useless in most cases by the rapidity of the
course of these sequelae; and, consequently, local applications form
the most important part of the treatment.

CHAPTER VIII.

SCARLATINA— SCARLET FEVER.
(CLASS IV.— ACUTE, EXUDATIVE, CONTAGIOUS DERMATOSES.)

Fehris Scarlatinosa, Afigina Maligna, Angina Eri/sipelatosa, Rossalia,
Rossania, Scharlach, Scarlachßeher, Scarlalitie, ^"c.

On account of the scarlet colour of the rash in this disease, the
name of Scharlach was given to it by German physicians ; and this
term was probably latinised by Sydenham. Earlier authors call the
malady Eosalia, Eossalia, and Rossania. AVhether the Greek,
Roman, or Arabian writers were acquainted with it, cannot be
determined from their works. Indeed, the first description of an
epidemic complaint resembling our scarlatina rather than any
other disease is that given by Ingrassias of Palermo and Coyttarus
of Poitiers in the middle of the sixteenth century. The character-
istic features of this exanthem may be recognised unmistakeably in
the writmgs of Sennert and Döring, who saw scarlatina in an epi-
demic form early in the seventeenth century. Towards the end of
the same century, Sydenham and Morton published the results of
their observations of epidemics which had prevailed in London. Of
these writers, the former admitted scarlatina to be an affection sul
generis, while the latter, on the other hand, maintained that it is
identical with morbilli. After this time the number of papers and
books on this disease increased rapidly, although they contained
comparatively little that was new. The writers of tlie natural his-
torical school placed scarlatina among the erysipelacea^.

The older literature of this disease was collected with industry
and care by J. Frank,^ and also by Most ;- more modern writings

* * Grundsätze der gesammt. prakt. Heilkunde,' Leipzig, 1843, iv Theil, p. 348.
' 'Versuch einer kritischen Bearbeitung der GescLiclite des Scharlachfiebers,'
Leipzig, 1836, Band ii, p. 345,

SCARLATINA (.MAYR). 189

upon the same subject are quoted by Caustatt;^ and still more
recent works will be found enumerated in Wunderliclf s ' Handbuch
der Pathologie und Therapie/^

Symptoms of Scarlatina.

Scarlatina is a general disease, manifested by a scarlet rash cover-
ing the whole surface of the body, or at least a large part of it, and
attended with fever, as well as with a more or less intense inflam-
matory affection of the organs of deglutition. It runs an acute
course, and is contagious.

Very difi'erent statements have been made by writers upon scarla-
tina with reference to the length of the period of incubation or
latency in this disease. According to some, it may vary from three
days to a month ; M'hile others limit it to six or seven days. In
certain cases it has been positively proved that, as early as the fourth
or fifth day after infection, the pulse has been perceptibly accele-
rated, and sensations of slight headache, with transient malaise
and weakness, have been experienced. Very often, however, the
first stage of the disease, the staclium prodromorum, sets in suddenly
with intense fever, without having been preceded by any of these
symptoms.

I. Stadium Prodromorum.

In reference to the number and severity of the symptoms ob-
served during this period, no rule can be laid down which will hold
good in all instances. But the observation of many cases renders
it possible to give a sketch of what may be regarded approximatively
as the typical form (Prototyp) of scarlatina.

T[\ws,febnle symptoms are present, as is shown by the pulse being
quickened, reaching even 140 beats in the minute, and by the skin
being hot and dry, its temperature being sometimes as high as 104°
Fahr.

The chief concomitant symptom in this stage of scarlatina consists
in a swollen and reddened state of the tonsils and soft palate. This
inflammatory redness sometimes extends from the parts originally

' ' Jahresbericht,' vol. ii, pp. loi — 105.
^ Band ii, i Abtheil, p. 544.

190 SCARLATIJ^A (MAYR).

afiected by it forwards over the tongue, and backwards to the mucous
surface of the throat ; but it seldom involves the Schneiderian
membrane or the conjunctiva^ and still more rarely the lining of the
larynx and trachea. At the same time, the patient suffers from
nausea, or even vomiting, and frequently is in a drowsy state.
The subjective symptoms of which he complains are difficulty
of swallowing, sensations of dryness and burning in the throat, feel-
ings of weight in the head, giddiness, or even severe headache.
There is also great muscular depression, and in children coma and
delirium are often present. Convulsions, again, are among the more
common symptoms ; while the patient much less frequently complains
of an ophthalmia, a severe catarrh, or a troublesome cough. This
stage may last only a few hours, or as much as three days.

II. Stadmm E^niptioyiis.

The/el/rile and concomitant si/mptoms gradually become more and
more intense during this period.

Exanthematic Symptoms. — The first signs of the scarlet rash are
observed on the neck and the upper part of the chest ; it appears in
the form of minute red points, closely aggregated together, and
smooth, so that the part looks as if uniformly reddened. The face
generally remains free from this efflorescence, excepting, indeed, that
it is slightly congested, and that the fever causes an increase in the
turgidity of the skin and in the rosy hue of the cheeks. Neither in
this nor in any subsequent stage of the exanthem does the face
generally present the true scarlatinal ernption.

^Vheu it first makes its appearance^ this rash has not a very
decided scarlet colour; it is sometimes of a pale, rose-red tint, dif-
fering in no respect from that of an ordinary erythema, which, ])ar-
ticularly in children, is often accompanied with fever. From the
symptoms as yet present, it is, in fact, impossible to determine with
certainty the nature of the complaint. One can at most, when this
exanthem happens to be epidemic, conjecture from the general aspect
of the case that it is one of scarlatina.

SYMPTOMS. 191

III. Stadium Floriiionis.

During the early part of this stage, botli the fehr'ile and the con •
comltant symjjtoms coutiuue to increase in intensity.

Exantliematlc Symptoms. — The rash above described as being con-
fined to the neck and chest, now gradually extends over the arms
and forearms, and also over the back, loins, and lower limbs ; in
fact, it spreads uniformly over every part of the body, but displays
a special predilection for the hands and feet. It is now, for the first
time, possible to diagnose positively the nature of the disease.

The efflorescence of scarlatina presents various shades of colour,
from a pale rose red to a dark scarlet. It disaj)pears beneath the
pressure of the finger, but returns instantly as soon as this is
removed; its reappearance proceeding either from the centre to the
periphery, or in the reverse direction, according to the kind of
pressure employed and the spot to which it is appplied.

The length of time during which the rash remains visible may
vary from a single day to a week j but, as a rule, it lasts three days.
Thus, the acme of scarlatina is generally reached on the second day
of the efflorescence ; after which, in cases in which the disease takes
its normal course, the pulse becomes less rapid, and the other con-
comitant s}Tnptoms decline. The lining membrane of the mouth, how-
ever, still remains universally reddened ; and so does the surface of
the tongue, unless it is covered with a white far ; for, in that case,
the deep-red colour and the enlargement of the papilhe are to be
seen only at the apex and on the sides of the organ. In some
instances the patient again suffers, at this period of the disease, from
pain during deglutition, and the saliva is again secreted in increased
quantity. The urine is scanty, and there is generally constipation
of the bowels.

The subjective symptoms complained of by the patient consist in
a pricking, or itching, or, sometimes, even a burning, sensation in the
skin. I have never been able to recognise in this disease any charac-
teristic smell, although Heim states that he can detect an odour
resembling that of mouldy cheese, or of the dens of beasts of prey.

When the efflorescence begins to disappear, the order of succession
in which it fades from the different regions of the body is the same
as that which it observed when making its appearance. At the end
of two or three days all the parts affected present a brownish colour,

192 SCARLATINA (mAYH).

due to pigmentation, and of an intensity proportionate to that of
the scarlet rash which, preceded it. Within the same period the
temperature of the skin and the frequency of the pulse again become
normal, and the inflammatory state of the mucous membrane of the
mouth and throat gradually subsides. The alvine evacuations fre-
quently become more fluid, and also more abundant. The urine,
too, increases in quantity ; and traces of albumen, as well as nume-
rous epithelial cells, may often, even at this stage of the disease, be
found in it, although they are sometimes present for only a very
short time. The ordinary duration of the stadium Jlontionls, up to
the commencement of desquamation, is about six days.

IV. Stadinm Besquamationis.

During this period both the fehrih and the concomitant sijinptoms
continue steadily to decline.

The only exanthematic s^mjdom is the desquamation. This begins
on the neck, the part at which the rash first appears, and at which it
also commences to fade. The epidermis of this part generally
peels off in the form of fine lamellce, so that parts of skin of greater
or less extent, although healthy, are observed to be surrounded by a
white border. According to the intensity of the previous efflorescence,
the mode of desquamation is different. Thus, the cuticle sometimes
separates in large plates, and even (from the fingers, for example) as
a complete membranous glove [Desquamatio memhranaced) ; while,
in other instances, it forms small branny scales [Desquamatio fur-
furacea). The former variety is generally observed on the hands,
feet, forearms, and legs ; the latter occurring on the other parts of the
body. Wittering and Most have asserted, that in some cases of
scarlatina they have seen the hair and the nails cast off. However
slight the desquamation may be, traces of it are always to be detected
upon the chest and the sides of the neck. It lasts, on an average, about
fourteen days; but on the fingers, palms, and soles, it requires a
longer time for its completion than on other parts of the body.

According to this description, then, the whole course of scarlatina,
from the beginning of the stadium prodromorum to the end of the
period of desquamation, occupies from two to five weeks.

VARIETIES. 193

Varieties of Scarlatina.

The sketch I have just given of this exanthem is appKcable to
that form of it which preponderates among sporadic cases and in
the milder epidemics. But in some instances the disease deviates
altogether from this normal type ; and this is observed far more
frequently in scarlatina than in either measles or smallpox. Scarla-
tina then is, both in its symptoms and in its course, the most irre-
gular of the three contagious eruptive fevers, so that it is in fact
impossible to mention all the varieties which present themselves in
practice. I shall therefore content myself with describing the most
important of the modifications of this exanthem, passing over those
which are of less consequence.

I . Prolongation of the period of Latency.

According to my own observations, the interval between the oc-
currence of infection and the outbreak of the disease is, in some
cases, as long as a fortnight. MM. RilUet and Barthez^ indeed,
assert that still longer periods, such as a month or even forty days,
may elapse after exposure to contagion. Upon this point, however,
I would not venture to give a positive opinion. A prolongation of
the stage of incubation is observed chiefly in children already in
bad health, affected with rickets, or suffering from some one of
the various neuroses.

2. Irregular Development of the Rash.

The efflorescence in some cases appears suddenly, no previous
symptoms having existed, and the fever and inflammation of the
throat arising subsequently. It is, however, necessary to bear in
mind that the tonsillitis and other affections generally observed
during the stadium prodromorum are often, when present, very slight,
so that they may easily be overlooked. In fact, careful observation
teaches that it is only in very rare instances that redness of the
mucous membrane of the throat is altogether wanting.

Another variety consists in the rash breaking out in an irregular
way. Thus, it sometimes appears on regions of the body which are
kept warm, such as the loins, back, abdomen, elbows and knees, earlier

194 SCARLATINA (mAYR).

than on the neck or chest. Like the other exanthemata, too,
scarlatina affects first, and with most intensity, parts which have
been previously exposed to pressure or friction {ßrytJiema trauma-
ticum). Hence, if we would avoid mistakes, we must not overlook
the fact that an eruption may possibly belong to this disease, even
though it is for a time quite local.

Sometimes, again, the scarlatinal efflorescence breaks out sud-
denly over the whole cutaneous surface, instead of appearing in suc-
cession at different parts of the body. This is a rare occurrence in
sporadic cases, being observed chiefly when a severe epidemic is
commencing or is at its height.

Further, the eruption is in some instances imperfectly developed,
so as to consist merely of isolated patches, each as large as the palm
of the hand, or larger, scattered over various parts of the body, the
skin between being sometimes quite healthy, sometimes (but only
during the exacerbations of fever) covered with a fugitive rash. On
the surface of paralysed limbs, the scarlatinal efflorescence is often
altogether wanting. In some cases, lastly, this rash has been
confined to one lateral half of the body.

3. Irregularities in the oration or intensity/ of the Efflorescence.

The rash of scarlatina appears to be occasionally so evanescent as
to remain visible for a few hours only. The case would then be
regarded as one of a simple erythema, did not the presence of con-
comitant symptoms, or the protracted course of the complaint,
taken together with the 'prevailing epidemic constitution, enable a
correct diagnosis to be made.

Sometimes, again, we observe the exact opposite of this, the
stadium floritionis being prolonged, so that the rash remains out
for a week, or even, in exceptional instances, for several weeks.
When this is the case, however, it does not present the usual scarlet
coloui', but acquires a livid tint, and ends in a deposit of very dark
brown pigment.

In another variety which is now and then met with, the efflo-
rescence is unusually intense, the whole surface of the body appear-
ing as if suffused with blood. Again, it is sometimes so pale that
a careful examination is necessary for the detection of the slight
punctated redness.

Lastly, there are some cases in which the rash successively

VARIETIES. 195

vanishes and reappears. These alternations, which occur at in-
tervals of variable length, depend sometimes upon changes in the
amount of fever present, sometimes upon the presence of internal
diseases as complications of the exauthem.

4. Irregularities in the process of Desquamation.

In some cases of scarlatina, the commencement of desquamation
is retarded; in other instances, — and chiefly when oily or fatty
matters have been re}3eatedly rubbed into the skin, — its duration is
much longer than usual. A desquamation excessive in degree is, as
a rule, the result of a very intense rash, while one which is un-
usually scanty is generally the sequel of a no less slight efflo-
rescence.

5. The " Scarlatina sine Exanthemate."

The use of this expression can be justified only in such cases as
the following : — Several persons, residing in the same locality, and
exposed to similar epidemic influences, fall ill at the same time :
some of them present, in a well-marked form, all the symptoms of
scarlatina ; others suffer merely from fever and an affection of the
throat, there being in these patients no efflorescence, nor, at a later
period, any desquamation.

6. Irregularities in the form of the Rash.

The following varieties of the scarlatinal eruption may be recog-
nised :

(i) Scarlatina Icevis. — The smooth, simple efflorescence — the most
common form, upon which I have based the description given above.

(2) Scarlatina lavigata. — Canstatt has applied this name to a
more intense variety of the disease, characterised by the shining
appearance of the rash, and by the mucous surfaces being affected in
a more marked degree.

(3) Scarlatina papulosa. — In this form, which is, however, rarely
met with, small papules of a dark red colour, which give a rough
feel to the skin, and are due to an unusual degree of swelling of the
mouths of the hair-sacs, arise on the reddened surface of the parts
affected. In some cases such papules are observed as long as twelve

196 SCARLATINA (MAYR).

or eighteen hours before the ordinary scarlatinal rash makes its
appearance.

(4) Scarlatina miliaris (Scharlachfriesel). — This variety — one
less rare than that just described — is characterised by the formation
of white vesicles seated on a red base, and filled with a transparent
fluid. They often cover large tracts of the cutaneous surface, but
are observed principally on the trunk of the body. In some cases
of scarlatina, however, we find groups of similar vesicles on the inner
surfaces of the arms and thighs, as well as on the neck, back,
chest, and abdomen. This is the so-called Miliaria alha.

(5) Scarlatina variegata (Der gefleckte Scharlach, Rubeola scar-
latinosa).— In this form of the disease the red points, from which
the efflorescence normally developcs itself, enlarge so as to form
defined maculae, as big as lentils or beans, and of an intense red
colour. These spots are found in large numbers on the limbs
and trunk. Every part of the surface is, in these cases, covered
with a continuous and uniform, but paler, rash; and the in-
tervals between the darker macula? arc, consequently, never of the
colour of healthy skin. After a short time these darker spots some-
times coalesce, and so again produce a continuous eruption of a
very deep hue. In other instances, however, they undergo no such
change, but, throughout the whole course of the complaint, present
the same appearance as when they were first formed.

(6) Scarlatina hämorrhagica sen septica. — Instead of the minute
dotted efflorescence, readily disappearing beneath the ])ressure of the
finger, there are seen, in this form of scarlatina, reddish-brown points,
placed close to one another, and surrounded by a diffused rash of a
paler colour. These spots arise from haemorrhage, and are un-
affected by pressure, which obliterates only the scarlatinal eruption
between them. After a time they coalesce in places, the rash which
surrounds them acquires a bluish appearance, and thus are formed
sharply defined patches, each as large as a half-crown, or even as the
palm of the hand.

In children this variety of the scarlatinal efflorescence is often
observed over a large part of the surface ; but in adults it is con-
fined to the neck, the upper part of the chest, the back, and the
skin over the joints of the upper and lower limbs. When the rash
presents this hgemorrhagic form, the tonsils and gums are generally
of an abnormallv dark colour.

VARIETIES. 197

7. Modifications of Scarlatina, due to its heing combined vjith
oilier cutaneous affections.

According to the conception which we form of a morbid process
arising from a specific alteration in the bloody it cannot be admitted
that scarlatina ever coexists with smallpox or measles in the same
patient ; and therefore the cases of this kind related by certain writers
must be referred either to the Scarlatina variegata, or to the form of
smallpox in which the eruption is preceded by an erythema. Indeed,
observation shows that when an individual is attacked by two of these
diseases in succession, either the progress of the first is checked, or
the second fails to be developed. With reference to this point
Noirot says — "When scarlatina and measles coexist, the former
generally prevails ; the latter (like smallpox under the same circum-
stances) being, as a rule, suspended for a time, but subsequently
going through its regular course/^ In wards in which patients
affected with the different exanthemata lie side by side, persons
suffering from measles or smallpox are often attacked by scarlatina ;
but when this happens the scarlatinal rash does not break out till
the previous eruption has either passed into the stage of desquama-
tion, or even altogether disappeared. It is, indeed, stated that the
course of variola or morbilli may be suspended by an attack of scar-
latina, and renewed when it subsides ; but this I have never myself
had occasion to observe.

In some cases, besides the ordinary scarlatinal efflorescence, there
appear a few urticarious wheals, or even bullfc or pustules in small
numbers. These have been sometimes set down as a pemphigus
and an impetigo respectively; but this is not correct, for they
quickly disappear, and are not succeeded by any fresh eruption of a
similar character.

As I have already stated, Purpura is observed in combination
with the scarlatinal rash in the hsemorrhagic or septic variety of
this exanthem. Moreover, in certain cases, it presents itself during
the stadium floritionis as an isolated symptom; and this form of it
does not essentially modify the course of the disease.

Chronic eruptions, such as eczema, psoriasis, prurigo, or even
severe scabies, do not prevent the occurrence of scarlatina. While
this exanthem is present, however, they recede into the background,
but return with fresh intensity as soon as it has completed its course.

198 SCARLATINA (MAYR).

When scarlatina is combined with other febrile diseases, these^ as
is well known, display an unusual severity. Certain writers have
stated that this exanthem is often associated with typhus and with
the puerperal state, and have even made use of the expressions " Scar-
latina t^pJiosa 2i\\(\. S. 2}uerperalis." This name, however, is altogether
inappropriate, for the rashes observed under these conditions have
nothing in common with scarlatina except their colour, and are,
therefore, to be regarded as mere erythemata.

8. Comjilications of Scarlatina.

Certain of the affections which I have already mentioned, as pre-
ceding or accompanying the simple form of scarlatina, not infre-
quently pass into independent diseases. Tliis has the effect of pushing
into the background the cutaneous eruption, and causing it to un-
dergo essential changes in character, or even to disappear altogether.
In fact, the general aspect of the case is more or less completely
altered ; and this has given rise to the erroneous notion that these
complications of scarlatina are caused by a retrocession of the efflo-
rescence.

"Wlien speaking of measles I showed that the mucous membrane
of the air-passages is the most frequent seat of the secondary affec-
tions which are apt to make tlieir appearance during the course of
that exanthem. On the other hand, the structures generally first
attacked in the compHcations of scarlatina are the tonsils, the
arches of the soft palate, and the base of the tongue ; and the morbid
action afterwards extends by continuity of surface to the larynx^
oesophagus, fauces, or nasal cavities, and at the same time involves
the parts subjacent to those originally affected, such as the parotid
and submaxillary glands, and the surrounding connective tissue.
Thus we have —

I. Parenchymatous Inflammation of the Tonsils (Angina scar-
latinosa maligna) . — This, the more severe form of scarlatinal angina,
consists in an inflammation of the glandular structure of the tonsils
and of the adjacent areolar tissue. It may either precede or accom-
pany the first appearance of the rash, or even (which is less common)
arise during the stadium fl or itionis : it generally terminates in either
suppuration or gangrene. When these results have begun to mani-
fest themselves, but not before, the efdorescence commences to fade,

COMPLICATIONS. 199

or becomes reduced to a few patches of the size of the palm of the
hand, assumes a livid colour, and no longer disappears beneath the
pressure of the fiuger.

II. DipJitheriiis of the Tonsils and adjacent parts (Angina diph-
theritica seu crouposa) . — This is observed chiefly in certain epidemics
of scarlatina ; it affects adults as well as children, and is not confined
to those actuall}'- suffering from the disease, but attacks even persons
who have merely been brought into contact with patients ill with it.

The presence of diphtheritis has no tendency to " drive in" the
scarlatinal rash, which, in these cases, is often abundant and intense,
and is accompanied by great heat of skin. Should, however, the
efflorescence suddenly fade, or the surface assume a livid appearance,
while the temperature at the same time falls, an unfavorable pro-
gnosis must be given, for these symptoms point to the existence of
some general disease which is already far advanced.

III. Inflammation of the Areolar Tissue of the Nech, and of the
8iihriaxiUary Glands. — This complication of scarlatina must not be
confounded with the similar disease which accompanies and is caused
by a tonsillitis ; it is rather to be compared with the metastatic affec-
tions observed in typhoid fever. It makes its appearance during the
stadium floritionis of the exanthem, or soon after the end of this
period, and sometimes terminates in resolution, but more frequently
in suppuration, or even, in certain cases, in gangrene.

The liability to this affection is by no means confined to those
individuals who suffered from disease of the glands before being
attacked by the scarlatina. It occurs also in those who were pre-
viously to all appearance perfectly healthy : I have, however, fre-
quently seen it in the children of syphilitic parents. This complication
cannot be said to modify to any extent the scarlatinal rash. Even
when suppuration or gangrene sets in, the efflorescence still remains
visible, but acquires, in patches, a livid colour.

IV. Inflammations of the Serous Membranes. — These affections, as
complications of scarlatina, are rare in comparison with those of
which I have hitherto been speaking ; hence we may infer that they
arise from something special to the individual patient, rather than
from any general condition. They are observed in adults more com-
monly than in children. The slightest form in which they occur is
as rheumatic affections of the joints. This acute articular rheumatism

200 SCARLATINA (MAYR).

is generally of short duration^ and of little intensity ; but it should
not be disregarded, for it often precedes or accompanies some more
severe disease, such as meningitis, pleuritis, pericarditis, or peri-
tonitis.

When, during the course of a scarlatina, a large quantity of
effusion is rapidly poured into one of the serous cavities, the rash
disappears ; but if the exudation occurs at intervals, and not all at
once, the efflorescence generally returns for a short time with each
fresh exacerbation of fever.

V. Pneumonia of a Croupous cJiarader. — This affection, either in
the lobar or lobular form, is often associated with other complica-
tions of scarlatina, such as gangrene, pleuritis, &c. ; and in some
cases, though less frequently than in measles, it is itself the pre-
dominant disease. It then arises by the extension downwards of
a croupous bronchitis, and may, therefore, be correctly termed a
hronclio- pneumonia.

This complaint does not constantly produce any change in the
scarlatinal efflorescence ; nor does it, generally speaking, lengthen to
any great extent either the stadium jhritionis or the stadium
desquamationis. In some few cases, however, the latter period is
prolonged by the occurrence of this complication.

Tii. Inflammation of the Intestinal Mucous Membrane. — This
affection generally sets in when the exanthem is fully developed. It
is more often of a catarrhal than of a croupous character, and gives
rise to diarrhcea, accompanied with dysenteric symptoms.

VIII. The following diseases also require to be mentioned as being
among the more rare complications of scarlatina : — Sloughing of the
cornea (Keratomalacie) ; ozsena (Ehinorrhagie) ; stomatitis vesiculosa
seu aphthosa ; pulmonary apoplexy ; and gangrene. This last fol-
lows the application of blisters, or affects parts previously diseased,
or the seat of bed-sores.

It is only in very rare cases that any one of the complications I
have been describing occurs altogether apart from others. Most
frequently two or even more of them are present simultaneously.

IX. Scarlatinal Dissolution of the Blood (Scarlachtyphus) . — It is,
however, not uncommon for scarlatina to terminate fatally after
running a most violent course, without our being able to make out,

COMPLICATIONS. 201

either during life or after deaths that any particular organ or system
of organs is especially diseased. Now, cases very similar to these
are observed likewise in the other exanthemata and in typhus ; and
taking this fact into consideration, we are ready to admit the validity
of the explanation wliich regards them as instances of a scarlatina
without locahsation and affecting the blood alone (eine Scarlatina
ohne Localisation, ein im Blute verlaufender Scharlach), or, 'in other
words, as the effect of a scarlatinal dissolution or decomposition of
the blood.

These cases present two grades in the intensity of the symptoms
with which they are accom])anied. In the more severe of these two
varieties, extreme muscular depression, with slight headache and
a remarkably rapid pulse, are present from the very commencement
of the febrile disturbance. These symptoms are followed during the
stadium erupiionis by repeated vomiting, and afterwards by a deep
stupor or delirium. The patient lies on his back, with his eyes half
open, but in an unconscious state. "When loudly spoken to, he
seems to come to himself, and answers the questions put to him, but
soon sinks back into his original posture, and becomes again un-
conscious. Quivering movements of the muscles of the face and of
the fingers are also commonly observed in these cases, and, in
children, general convulsions often occur. The pupils are moderately
dilated ; the lips and tongue are dry, the latter being usually of a
bright red colour. As the disease goes on, mucous rales are heard
in the larger bronchial tubes ; the abdomen becomes distended, but
there is seldom any enlargement of the spleen ; the mine becomes
scanty, and of a dark red colour ; the pulse continually increases in
frequency, reaching as much as 160 beats a minute; the features
become sunken, and the extremities cold ; and death generally follows
very rapidly, the usual duration of this form of the disease varying
from twelve hours to five days.

Under these circumstances, the scarlatinal rash may be modified
in different ways. Sometimes the disease sets in so suddenly, and
with such violence, that there is no time for the efflorescence even
to make its appearance; and in such cases we may often be in
doubt as to the cause of the patient's rapid death. Sometimes,
again, the eruption comes out, but only in patches, and, after a
short time, disappears ; while, in other instances, it developes itself
with great intensity over the whole cutaneous surface, being at first
of a dark red hue, but soon becoming livid ; or, lastly, it becomes

203 SCARLATINA (MAYR).

reduced to a few large maculsej which are then, in most cases, of a
bkiish colour.

The second grade of this affection is the " scarlatina with tj^^hus-
like course " (Scharlach mit typhusartigen Verlauf ) of Löschner.
A state of stupefaction and muscular weakness, and a persistently
rapid pulse, without any discoverable local affection, are present in
this form of the disease, although in a much slighter degree than
in that above described. The patient is languid and indifferent, and,
even if a child, seldom asks to be taken out of bed. During the
evening exacerbations of fever, slight convulsive movements and
delirium are observed ; the patient tosses restlessly to and fro ; the
eyes are dull and half closed ; the mucous membrane of the mouth
and nose dry ; the lips covered with black sordes ; the thirst intense ;
the skin hot and parched. Symptoms of bronchial catarrh are
present ; the abdomen is tense, and on the application of forcible
pressure tender ; the urine is scanty, and in lialf the cases contains
a considerable quantity of albumen. Should the disease be of long
duration, a catarrhal diarrhoea comes on; there is a persistent
acceleration of the pulse, which during the exacerbations reaches
1 60 beats per minute, but is still in due proportion to the frequency
of the respiration.

In cases of this kind the scarlatinal rash, though of a paler colour
than usual, generally developes itself in the regular way, and seldom
disappears prematurely. It is often accompanied by petechipe, or
by miliary vesicles.

In the post-mortem appearances observed in these cases there are
certain points of interest.

The first striking fact is the presence of gray granulations on the
membranes of the brain. These are found more often in cases in
which the disease was acute than in those in which it ran a more
slow course. They are met with chiefly in children, and occur in no
other disease excepting acute hydrocephalus and miliary tuberculosis.^

1 It is impossible not to be struck by the fact that the description of these
" gray granulations" reads remarkably like an account of the Pacchionian bodies.
Prof. Mayr speaks of them as being " of the size of poppy-seeds, and
aggregated together in groups," and as " being detached -with difficulty from
the membranes of the brain. They are found at the summit of the hemispheres,
on either side of the falx cerebri, and sometimes, in small numbers, on the
lateral surfaces of the pons Varolii." The original work, contains a detailed
account of the post-mortem appearances in these forms of scarlatina, but this
has been omitted in the translation. — [Ed.]

SEQUELS. 203

A second appearaucCj constantly observed in these cases, is a
hypersemic condition of the brain, lungs, and abdominal viscera,
without any evident exudation being present.

A third point of importance is the fact that the Peyerian
patches in the small intestine are enlarged and reddened, although
very seldom ulcerated (excoriirt). Their condition bears a great
resemblance to that found in typhoid fever.

Lastly, it is remarkable that a very considerable quantity of serum
is in these cases contained in the large serous cavities.

Seqiielcs of Scarlatina.

Under this head I propose to speak of those affections which
manifest themselves by special symptoms only when the primary
disease has already run its course, but which nevertheless are clearly
developed out of, and generated by, the scarlatinal process.

Their effect on the scarlatina is not to complicate it, but to prolong
it ; and although their origin may often be traced back as far as the
commencement of the exanthem, yet it is not till after the end of
the stadium floritionis that they step into the foreground as inde-
pendent affections.

I shall not regard these sequelfe as produced by the deposition of
a scarlatinal poison which had been retained in the blood, and had
not been duly excreted. In my opinion, neither the scarlatinal rash
nor the subsequent desquamation has for its object to remove from
the body morbid matters of any kind whatever, or in any way to
purify the system. I look on them both as mere symptoms of the
general disease to which they belong.

Tor, in truth, sequelee arise quite as often in cases in which the
eruption ran its regular course, was fully developed, and lasted the due
time, as under the opposite circumstances. A sudden interruption in
the course of a scarlatina and a disaj^pearance of the rash are, as
I have already several times stated, generally the effect of the presence
of some complication of this exanthem.

Among the principal causes which dispose to the production of
sequelae in this disease, must be mentioned pre-existing scrofulosis,
rachitis, ansemia, syphilis, or scorbutus. Moreover, the restoration
of the patient to health may be retarded by his being placed under
external conditions of an unfavorable kind ; and, consequently, these

20-1 SCARLATINA (MAYR).

may likewise aid in giving rise to the affections with which we are
now concerned. In scarhatina, as in every other complaint, an
influence for evil may result from the patient^s food being insuffi-
cient or unwholesome, or from his lying in a damp room or ward, or
from his being deprived of fresh air, or, kstly, from his linen not
being properly changed.

The sequelcE of scarlatina are of two kinds : some of them are
simply continuations, but with increased intensity, of affections which
arose during the course of the primary disease; others are due
directly to the morbid state of the blood, which still continues.
These last either appear as inflammations of the glandular structures
or the synovial membranes of the joints, or take the form of exuda-
tions into the areolar tissue or the serous cavities.

The morbid conditions with which we are now concerned are the
following :

1. Ozcena post Scarlaiinam. — This occurs in scrofulous children,
and also in persons previously subject to disease of the nasal mucous
surface. According to Canstatt, a very dangerous form of this
affection has been frequently observed in epidemics which have
recently visited the coasts of the North Sea and the Baltic.

2. Diseases of the organ of Ilearivg are comparatively rare, but
are also among the most obstinate and serious of the sequelae of
scarlatina. They may arise in various ways. In the first place,
inflammation is apt to spread to the mucous membrane of the
Eustachian tube from the tonsils and soft palate, which (as "we have
seen) are often much swollen and in a state of suppuration ; and
thus the hearing may become temporarily impaired. The same
effect may, for a time, be caused by the pressure of the parotid
gland, when intensely inflamed, upon the external auditory meatus.
Moreover, certain independent diseases of the ear are liable to occur
during the stad'nim flonlionls of scarlatina, and to last for a shorter
or longer time after its termination. These are observed chiefly in
tuberculous or scrofulous subjects ; they generally consist in a
chronic inflammation of the mucous lining of the Eustachian tube,
or in certain pathological changes affecting the interior of the organ
of hearing.

A much more frequent condition, however, is the disease of
the external auditory meatus known under the name of otor-
rhcea. This is often the result of a parotitis, or of an inflammation
of the areolar tissue of the neck.

SEQUELAE. 205

Persistent deafness after scarlatina is happily rare, and, when it
occurs, is probably due to changes in the lining membrane of the
tympanum (such as the exudation of plastic matter, softening, or
suppuration), caused by the extension of inflammation along tlie
Eustachian tube.

It would appear that a metastatic origin must be assigned to the
form of Oliiis interna, which commences suddenly, and with very
violent symptoms, while the fever is at its height. This affection is
remarkable for the rapidity with which it destroys the interior of the
ear. It generally occurs on one side only, but often terminates
fatally by pyaemia, or from the extension of inflammation to the
membranes of the brain, erysipelas being at the same time present.
In some cases death occurs after several weeks from caries of tlie
petrous bone.

3. Chronic enlarcjement of and supimration In the Tonsils, after
scarlatina. — This is observed chiefly in subjects of scrofulous
constitution.

4. CrojipoHS inflammation of the large Intestine. — This is merely a
continuation and extension of the intestinal affection which has already
been mentioned among the complications of scarlathia.

5. Inflammation of the Glands, and of the surrounding areolar
tissue. — This sequela difi'ers from the disease of the same kind which
arises during tlie presence of the exanthem in running a chronic
course and in commencing during the period of desquamation. More-
over, in this afl'ection the inflammation generally attacks first the
structure of the gland itself, and afterwards the neighbouring con-
nective tissue. Children suffering from rachitis or tubercular disease
of the glands are especially liable to this complaint. In the great
majority of cases, the organ affected is either one of the parotid or
one of the submaxillary glands ; this beiug much more rarely a sub-
lingual gland, or one of tlie absorbent glands of the axilla or neck.

6. Arthritis metastatica post Scarlatinam. — This sequela, which
is rare, but very destructive in its effects, belongs not so much
to infancy as to the later years of childhood and to adult life. It
is generally associated with inflammations of internal organs, and
especially of serous membranes. It is analogous to the metastatic
diseases which arise in women after childbirth, or follow typhus and
other blood diseases. Any joint may be the seat of this affection ;
but the knees, elbows, and hip- joints are particularly liable to it.
It generally sets in at the time when desquamation begins.

206 SCARLATINA (MAYR).

7. Scarlatinal Dropsy. — This so far surpasses in frequency all the
other sequelae of which I have been speaking, tliat its occurrence
seems almost to be the rule, whereas their presence is quite excep-
tional. Hence, in monographs upon the subject of scarlatina, dropsy
is, with justice, placed first among the complications and sequelae of
this exantbem. In fact, in many of these it works, it is the only one
of which any mention is made. Some observers, indeed, have con-
sidered this affection to be so intimately connected with the essential
nature of the scarlatinal rash, and so necessarily associated with it,
that they have described the dropsy as part of the disease, under the
name of the stadkcm liydropicum. And certainly, in children, the
appearance of dropsy often completes the diagnosis, or enables the
physician to determine that a scarlatina which had escaped notice
has been present. It is, however, impossible to state in general
terms, even approximatively, the conditions which give rise to this
sequela ; for every epidemic of tlie exantbem presents peculiarities
of its own, the other circumstances remaining unaltered. Thus, in
some epidemics dropsy occurs in almost every case, while in others
it is rare ; and yet no sufficient explanation of these differences can
be found, whether in the treatment or management of the patients,
or in the season of the year, the weather, the state of the barometer
or thermometer, the direction of the wind, or any other cosmical or
telluric influences.

Hence the question cannot but press itself upon the mind of every
observer — What is the came of the occurrence of dropsy after
scarlatina ?

This question has, of old, received very different answers, accord-
ing to the state of medical science at the time and the prevalence of
theoretical or practical views. Our forefathers attributed dropsy
either simply to the scarlatinal rash being imperfectly developed ; or
to its having (as was said) undergone retrocession in consequence of
the patient having caught cold ; or to the absence or suppression
of the critical sweat ; or, lastly, to the skin not having been duly
attended to (Vernachlässigung der Hautkultur), which last expres-
sion they did not more precisely define. But, by the careful chnical
observation of children and grown-up persons affected with this
disease, but living under the most varied conditions, it has been
shown that no one of the above-mentioned etiological conditions
affords an adequate explanation of the occurrence of scarlatinal
dropsy.

SEQUELS, 307

In the first place^ it is certain that from the greater or less intensity
of the rash in a particular instance ^ve can draw no absolute con-
clusion, whether favorable or otherwise, and that the amount of
eruption stands in no causal relation whatever with the consecutive
dropsy ; for, in my experience, this sequela has been observed both
in cases in which the ef&orescence had been fully developed, and
in those in which the skin was but very slightly reddened.

Nor does this complaint in any way depend upon the degree of
desquamation, which, indeed, is well known to vary directly with the
intensity of the efflorescence ; the fuller the rash, the more profuse
the subsequent shedding of the cuticle. Hence the very same
reasons which prevent my ascribing the dropsy to the former con-
dition render it equally impossible for me to attribute it to the
latter.

Again, no one of the supposed causes of this affection is more
generally called into requisition than that Avhich is known as
'' catching cold" (die sogenannte Verkühlung). This, however, is a
relative term, and so vague in its application that even medical men,
much more the friends of the patient, have recourse to it to account
for the occurrence of a dropsy explicable in no other way, although
he may have been most carefully covered up, and not allowed to
leave his room, or even his bed. But I have repeatedly had occasion
to observe that, in the absence of other exciting causes, neither this
nor any other of the sequelae of scarlatina arises from the patient
being kept cool, or even from his being exposed to the most severe
weather. Thus I have myself seen instances in which children,
during the whole coui"se of a severe scarlatina, have attended school,
and even in winter have run about the streets as usual, but in whom
the disease was followed by no sequelee ; whereas, at that very time,
other children, treated lege arils, well protected, and confined to their
beds, became dropsical and died.

In fact, if I could refer to no other recent cases, it would be suf-
ficient to draw attention to the favorable results obtained at
Gräfenberg by Priessnitz, who not only treated scarlatinal patients
with cold ablutions and afi'usions, but even allowed them to remain
in the open air. Certamly, no one under his care had any fear of
catching cold.

I think, then, that I may venture to assert that persons affected with
scarlatina, in whom there is no internal predisposing cause of disease
(ohne eine bestechende innere Ursache der Erki'ankuug), may be

J^08 SCARLATINA (MAYR).

exposed to not inconsiderable changes of temperature without any
danger of the ill effects which are generally dreaded.

As for the retrocession of the perspiration (das Zurücktreten der
Schweisse), the expression is, in the first place, obsolete. For the
sweat, being already an excreted fluid, can no more be reabsorbed
than urine which has been passed under one in bed. But, as is well
known, it is in every acute febrile complaint a good sign that the
perspiration should be abundant, and the skin soft and not intensely
hot; while, on the other hand, the cessation of the skin's action,
and a hot and dry condition of the surface, are always unfavorable
symptoms. Now if, in a case in which the cutaneous secretion was
previously abundant, an exacerbation of the fever should occur, or if
any new complication should set in, the salutary perspiration will
generally cease ; but, under such circumstances, this is obviously the
result, and not the cause, of the aggravation of the disease.

It is very much the same with the so-called retrocession of the
scarlatinal efflorescence. To our forefathers, the rash was the only,
or at any rate the principal, symptom of the complaint ; and there-
fore we can understand that they should have attached great im-
portance to its presence. But we now know that it is but a part of
the whole disease, and that the 'greater or less intensity of this
symptom, and its shorter or longer duration, are far from being the
sole or even the chief indications of the severity of the scarlatina.
Moreover, in complaints attended with a hypersemic state of the
skin, the sudden disappearance of the rash is always a proof that the
disease has previously undergone aggravation, which renders the
surface anaemic, because a condition of general collapse is induced.

Thus, then, a moderately developed rash, and the presence of but
slight fever, are to be considered good signs in scarlatina j and, on
the other hand, it must be regarded as unfavorable that the efflo-
rescence should suddenly fade, and that intense febrile distui-bance
or any severe complication should set in. But every one who is
acquainted with the facts to which I have been referring will look
on the disappearance of the rash as the eßect^ and not the cause, of
the aggravation of the disease ; and such a person certainly will not
attribute the occurrence of dropsy to a retrocession of the efflores-
cence.

Since Dr. Bright first drew attention to the pathological changes
in the kidney, and to the alteration in the chemical constitution of
the urine, which exist in chronic forms of dropsy, his conclusions

SEQUELiE. 209

have been extended and perfected by observations based on post-
mortem examinations, as well as by microscopical and chemical
investigations ; and, during this time, it has gradually become the
general 'opinion that the dropsy which follows scarlatina is the
immediate result of an albuminuria, that is, of Bright's disease of
the kidney. But although this discovery explains one of the
intermediate steps in the production of this effect, it does not teach
us the primary cause of the dropsy. The further question arises, —
what is it that gives rise to the renal disease and to the albuminuria ?
Now, some have given an answer to this question, on the principles
of the older school of pathologists, by attributing the affection to
the patient having caught cold, or, in other words, to the very
agencies which we have already been discussing ; while others, in
the spirit of more modern opinions, have ascribed it to the presence
of a foreign element, the scarlatinal poison, which, they suppose, still
remains in the blood. Even this last view may be said to be the
representative of the ancient doctrine of imperfect crises.

The explanation given by these writers is, then, somewhat of the
following kind : — Although the scarlatinal poison cannot be demons
strated by any chemical or physical tests, there is yet no doubt of its
existence. The organ which excretes it is the skin, of which the action
is, therefore, reciprocal to that of the poison. The complete elimi-
nation of this substance may be effected by a very intense efflores-
cence ; and, according to others, by profuse sweating, an abundant
desquamation, and a certain degree of renal congestion. But if
elimination does not occur, there then arise certain pathological
changes in both the skin and the kidney, or in one of them only.
The poison is, in fact, a second time, or repeatedly, determined to
the cutaneous surface. This does not give rise to a fresh efflores-
cence, because the vital activity of the skin has been weakened by
the previous specific inflammation. Consequently, a watery effusion
is poured into the subcutaneous tissue. Again, the increased efforts
of the kidneys to eHminate the poison produce a congestion of these
organs, and, as a result of this, a diminution in their secreting action.
The congestion leads, ultimately, to an exudation into the tubes of
the cortical substance. Part of the material thus thrown out is
excreted in the urine in the form of albumen ; the remainder becomes
deposited, and forms granulations in the substance of the kidneys.
Lastly, the diminished secretion of Urine leads to fresh effusion into

210 SCARLATINA (MAYR).

the subcutaneous areolar tissue, and into the serous cavities (Beh-
rend) .

As to the vahdity of this hypothesis, I cannot at the present
time express a positive opinion ; and I am the less inclined to speak
decidedly about it, because daily experience certainly teaches that
albumen is found in the urine under other conditions, as well as in
scarlatina and in the acute form of Morbus Brightii. This is the
case, for instance, during pregnancy, and also in many of the so-
called blood diseases (such as typhus, purpura, puerperal affections,
&c.), in which, although dropsy may be present, no connection can
be shown to exist between this symptom and the albuminous state
of the urine.

Moreover, if we examine the urine of a scarlatinal patient several
times each day, testing separately each quantity passed, we arrive at
the very interesting fact that even though some specimens contain
albumen, others may be altogether free from it. Thus this sub-
stance may be present in the morning urine, and yet absent in that
excreted in the evening, or vice versa. In some cases, again,
albumen can be detected only during one day, or even on but one
occasion; and when this occurs, no dropsy makes its appearance
either at the time or afterwards.

The period at which scarlatinal dropsy begins varies greatly in
different cases. The earliest symptoms of it may be observed either
at the commencement of the exanthem, or during its course, or in
the stage of desquamation. Most frequently, however, it commences
during the second or third week of the disease, that is to say, when
the rash has completely disappeared and desquamation has begun.

It has been stated by many observers that the sixth week is the
latest period at which dropsy ever makes its appearance ; and, in
consequence, the precautionary measures have been systemically
carried to the end of that time. However, in the cases of scarlatina
which have come under my observation, this sequela, if it has
appeared at all, has always commenced within four weeks.

It is of practical importance to notice whether the dropsy is acute
and attended with somewhat intense fever, or developes itself slowly
and gradually, with but slight februe disturbance. In the first
case, it is termed active dropsy ; in the second, passive.

In the active or acute form of this affection, the effusion of serum
takes place very rapidly, and is attended with increased vascula

SEQUELS. 211

action, and mth. pain, due to the liypersemia and the tension of the
parts affected. In fact, so far as the internal organs are concerned,
the symptoms of this kind of dropsy are so similar to those of
inflammatory affections (Exsudatbildung), that no strict line of dis-
tinction between them can be drawn. Nor is it less difficult to
define the limits between the active and the passive forms of dropsy ;
for even effusions which take place slowly may occur by fits and
starts, and be attended at one time with more, at another with fewer
inflammatory symptoms.

The principal kinds of dropsy consecutive to scarlatina may be
arranged in their order of frequency as follows : — anasarca, dropsy
of the serous cavities, cedema of the lungs, oedema of the brain,
oedema of the glottis, general dropsy.

(i) Anasarca forms two thirds of the whole number. Its cha-
racters are those ordinarily observed in dropsy due to renal disease.
While it is present, the desquamation seems to be suspended, in
consequence of the saturation of the layers of epidermis with fluid ;
but when the swelling has completely subsided, the cuticle again
begins to peel off, being apparently enabled to do so only by the
removal of the tension caused by the serous effusion.

This affection not only often occurs alone, but also frequently
precedes or accompanies ascites or one of the other forms of dropsy.

(2) Ascites.

(3) Hydrotliorax. — This is observed less frequently than the
preceding varieties ; its course is often remarkably rapid.

(4) Hydropericardium. — This very rarely occurs by itself, forming,
in most cases, part of a general dropsy.

(5) (Edema of the lungs. — This is observed in association with
general anasarca, and particularly with hydrothorax.

(6) (Edema of the glottis. — This, again, often coexists with
cedema of the lungs.

(7) (Edema of the pia mater and the cerebral substance. — This
affection is met with only in cases of prolonged general dropsy, in
which, indeed, it seldom fails to occur.

It sometimes appears to develope itself rather rapidly, with
symptoms of drowsiness, &c.

(8) Hydro][)S ventriculorum cerebri. — This variety, although always
mentioned in text-books among the other forms of dropsy, is in
reality seldom observed in cases of scarlatina.

Under the name of Etice^jhalopathie albiimiuuriq^ue^ MM. ßilliet

212 SCARLATINA (MAYR).

and Bartliez^ describe a complication of scarlatina in which severe
and acute cerebral symptoms present themselves, such as are observed
in ordinary Morbus Briglitii. This affection appears between two and
four weeks after the commencement of the anasarca, lasts from one to
seven days, and terminates, for the most part, in recovery. The
difference between it and other cerebral diseases is the fact that,
when it subsides, the patient perfectly recovers the power of sensa-
tion and motion, as well as his intellectual faculties. I am not,
however, disposed to adopt the name proposed for this affection by
MM. Rilliet and Barthez, and, therefore, I content myself with a
simple reference to their observations.

I must, however, take care to mention the not unimportant fact,
that when albuminuria has once occurred as a sequela of scarlatina,
it is liable to return, even though it may for a time have completely
disappeared. This is particularly the case with patients anaemic
from other causes, in whom it may thus recur several times, with
more or less well-marked dropsy, so as even ultimately to prove fatal.
If it takes place at all, a relapse is generally observed within two
months ; but one instance has come under my notice in which the
albuminuria returned, with great intensity, after four months had
passed. Even then, however, although the urine contained blood,
and also fibrinous casts, the patient ultimately recovered.

In conclusion, I have to remark that, besides those which have
been mentioned, many other diseases be observed after scarlatina.
Among these are inflammations of various internal organs, typhus
and intermittent fever. Moreover, certain chronic complaints, such
as tuberculosis^ and rickets,"' are frequently aggravated by an attack
of this exanthem. None of these affections, however, deserve to be

^ 'Traite cliuique et pratique des Maladies des Enfants,' 2oie ed., tome iii,
p; 182.

* MM. Rilliet and Barthez (op. cit., torn, iii, p. 201) were, iudeed, led by tbeir
observations to couclude tliat tuberculous children are seldom affected with
scarlaliua, and even that an attack of this exanthem gives tuberculosis a
teudency to undergo a rapid cure. These writers therefore believe that the
diseases in question are mutually antagonistic. My experience, unhappily,
does not confirm these statements.

^ In little children, the aggravation of rickets by scarlatina is often expressed,
during life, by the presence of pain in the cylindrical bones, which are particu-
larly tender on pressure ; and, on post-mortem examination, these bones are
found to present numerous osteophytes (zahlreiche Osteophyten).

PROGNOSIS. 213

termed sequela of scarlatina ; for they do not stand i]i a sufficiently
irect relation to this disease.

Prognosis of Scarlatina.

External and internal conditions of every possible kind combine
to modify the course taken by this disease in different instances^ and to
determine its issue in recovery or death. That scarlatina, even in the
mildest form, is never a trifling complaint, is a maxim which has
been only too fully verified by many sad cases. However favorable the
early symptoms, the appearance of some complication may render the
disease serious ; and even when the exanthem has run its course in
a perfectly regular way, there is still the danger that one of the
sequelse may present itself. Hence, in a case of scarlatina it is
scarcely possible to give what is termed v^ prognosis ; for our predic-
tions are always liable to be falsified by the events of the very next
day. We are, in fact, unacquainted with any means of measuring
the intensity of the disease. No correct conclusion as to the
probable issue of an attack of this exanthem can be drawn, either
from the bodily condition of the patient, from his having previously
passed through other complaints, from his age, nor, lastly, from the
external circumstances under which he is placed. In malignant
epidemics, scarlatina carries off persons (both children and adults)
the most robust and most carefully nursed, just as rapidly as those
who are sickly and neglected.

Hence, in this disease, every fresh symptom of an unusual kind
should be regarded with suspicion ; and the greatest caution must
be observed in predicting that any particular case will terminate
favorably.

The most important point of all, as the basis of a conjectural
prognosis, is the character of the prevailing epidemic. At certain
times, scarlatina is attended with most fatal complications, which
may even set in before the rash makes its appearance, and form a
more prominent feature of the disease. Cases are recorded in which
the very first symptom observed was a diphtheritis or a gangrene,
and in which death occurred before any one had an idea that the
patient was affected with scarlatina.

Again, even sporadic cases of this exanthem take a peculiarly
malignant course during the prevalence of certain complaints, such

314 SCARLATINA (MAYR).

as typhus, cholera, or dysentery. On the other hand, it may be the
sequelae of scarlatina, rather than the complications, which form
the principal cause of anxiety. In certain epidemics, dropsy is
more common and runs a more fatal coui'se than is usually the
case.

In conclusion, all my present experience leads me to say, with
Löschner, that I have never yet seen a henign epideynic of scarlatina.
Towards the end of every epidemic, however, the cases are generally
more simple, and run a more favorable course. My own observa-
tions do not lead me to attribute to the season of the year any
perceptible influence upon the issue of this exanthem.

With reference to the value of individual symptoms as indications
of the probable course of scarlatina, I may malce the following re-
marks : — An unusual lengthening of the period of incubation forebodes
that the course of the exanthem itself, as well as of its sequelae, will be
irregular. The appearance of the rash simultaneously with the so-
called prodromi,or its breaking out suddenly over the whole surface of
the body, announces a violent attack of the disease. If no severe febrile
symptoms nor any complications are present, the fact that the
efflorescence is incompletely developed may be taken as a sign that
the scarlatina will run a rapid and favorable course ; but if an im-
perfect rash is accompanied by intense fever, or by any unusual
symptoms (such as delirium, sopor, dysphagia, or dyspnoea), it then
indicates the presence of some perilous complication. The sudden
disappearance of the eruption, when it had been fully developed —
its retrocession, to employ the usual term — arises from some danger-
ous condition, and, consequently, is, in most cases, of evil omen.
On the other hand, the persistence of the rash beyond the usual
period, particularly should it no longer fade beneath the pressure
of the finger, if not caused by any previous chronic cutaneous
affection, points to the continuance of some internal disease, generally
of the lungs or air-passages, which disease had arisen during the
stadium floritionis. Differences in the intensity of the exantheraatic
eruption or in the amount of desquamation are of no special pro-
gnostic import.

Among the various forms which the eruption may display, those
above described as the S. variegata and the S. miliaris are alone of
•impoi:tance, the former because it suggests the fear that the complaint
will be attended with obstinate bronchitis and pneiimonia, as compli-
cations or sequelae ; the latter because it is frequently a symptom of

PROGNOSIS. 215

pyaemia. However, when the miHarj'- efflorescence breaks out at the
same time as the ordinary scarhitinal rash, and the other symptoms
are not particularly severe, its presence is not of any great conse-
quence. But if such an eruption makes its appearance at a later
period (when the scarlatinal efflorescence is fully out), and if it is
accompanied with an extreme exacerbation of the fever, and with
sopor and delirium, gangrene or ulceration of the tonsils, inflamma-
tion of the lungs or of serous membranes, — in these cases it is
generally the immediate precursor of death.

Petechise and ecchymoses are of very serious import when asso-
ciated with other alarming symptoms, indicative of the state which
I have ascribed to a dissolution of the blood. The same may be
said, likewise, of bleeding from the nose, if accompanied with haemor-
rhage from other parts, such as the gums or the intestinal surface ;
but slight epistaxis by itself is often beneficial by giving relief to the
headache from which the patient suffers.

A diarrhoea, appearing early in the course of the disease, and not
very severe, is not a bad sign in adults; but if protracted and
accompanied with tumefaction of the abdomen, it tends to exhaust
the patient. In infants less than a year old, diarrhoea is always
dangerous.

The fact that in a particular case micturition is painful and the
urine scanty and albuminous at the commencement of scarlatina, is
a proof that the disease is severe, and is, indeed, an indication of
great danger to the patient, from the probability that acute dropsical
effusion will supervene. At an advanced stage of the complaint, too,
a deficiency in the amount of urine secreted is generally the pre-
cursor of dropsy.

The uniform continuance of the perspiratory action of the skin is
a good sign; and sweats breaking out suddenly are regarded as
favorable crises.

A soft regular pulse, its beats not much exceeding loo in the
minute, accompanies benign forms of scarlatina ; and the same may
be said of the respiration, when deep, and in due proportion to the
rate of the pulse, and of the temperature, when below 104° Fahr.
On the other hand, it is to be regarded as a bad sign that the pulse
should be hard, or very rapid (beating 120 to 160 times a minute),
or irregular, or intermitting ; or that the breathing should be either
much quickened or very slow; or, lastly, that the skin should be
pungently hot, its temperature being above 104° Fahr.

316 SCARLATINA (MAYR).

Among the complications of this exanthem, the more severe form
of dissolution of the blood is quickly fatal^ and that whether the
patient was or was not previously in good health. It is an ominous
symptom that sudden loss of conciousness, with extreme depression
of the pulse and of the muscular power, should occur at the very
commencement of the disease.

Parenchymatous inflammation of the tonsils is serious on ac-
count of the results to which it leads. If it should be accompanied
by delirium or convulsions, with intense hypersemia of the brain, the
near approach of a fatal termination is to be apprehended. Should
gangrene arise, we may still hope for the recovery of the patient, so
long as the gangrenous spot is circumscribed and the surrounding
parts are not oedematous. When an extensive diphtheritic affection
leads to sloughing, or spreads to the larynx so as to produce croup,
there is rarely any prospect of a favorable issue. Inflammation of the
areolar tissue of the neck is dangerous in proportion to its extent,
and to the rapidity with which it sets in. Its results are most
serious when it attacks the lower part of the parotid region, or the
neighbourhood of the submaxillary gland.

Eheumatic pains are in themselves of no consequence ; but they
must not be altogether disregarded, because they are liable to be
followed by affections of the serous membranes.

Peritonitis, pericarditis, pleuritis, pneumonia, bronchitis, are
dangerous complaints, even when they occur alone ; and as complica-
tions of scarlatina, they are, of course, no less serious. The same
thing may be said of dysenteric affections and of protracted diarrhea.

Some of the sequelae of this exanthem are of importance, from
their insidious course, and from their interfering with the functions
of the part affected, rather than from their exerting any injurious
action on the organism as a whole. Among these are the inflamma-
tions of the external auditory passage, and of the mucous membranes
of the nose and the Eustachian tube; hypertrophy of and sup-
puration in the tonsils ; and the inflammatory affection of the glands
and surrounding areolar tissue. On the other hand, the so-called
metastatic inflammation of the joints, the glands, or the organ of
hearing, is extremely dangerous.

When dropsy is present, a comparatively good prognosis is war-
ranted by the following circumstances : — The patient^s health having
previously been good ; the urine being pale and abundant, and con-
taining little or no albumen ; the skin being inchned to perspire ; the

ETIOLOGY, 217

serous effusion remainiug confined to the subcutaneous areolar tissue ;
the functions of the brain and those of the respiratory organs being
undisturbed ; and lastly, any decrease in the amount of csdema, even
though this amendment should be only transitory. On the other
hand, the prospect is more threatening when the patient was pre-
viously ansemic, or the subject of any dyscrasia (as, for example, in
children who are the ofFspiing of syphilitic parents, or affected with
scrofulosis or rickets) ; when albumen has been present in the urine
from the very beginning of the scarlatina, and goes on increasing in
quantity ; when the urine is of a dark colour and scanty, containing
pus, blood, fibrinous casts, or cells derived from the renal tubes
(Enchymzellen) ; lastly, it is a bad sign that the skin should be
dry, or the effusion very extensive, collecting in the interior of the
body, or that the concomitant fever should be intense.
Death occurs in scarlatina from the following causes : —

1. Trom dissolution of the blood, due to the scarlatinal poison.

2. From paralysis of the nervous centres, as a consequence of
plastic or serous effusions, meningitis, or cedema cerebri.

3. By suffocation, from acute oedema of the lungs or glottis, or
from serous effusion into the pleura and pericardium.

4. From pyaemia.

The mortahty of this disease is not the same in every epidemic,
but, on the contrary, varies considerably. Thus, in malignant
epidemics of scarlatina, 20 or 25 per cent, of those attacked die;
whereas, when the complaint is prevalent in a mild form, it often-
times does not carry off more than 5 per cent, of those affected
with it,

Miology of Scarlatina.

The contagiousness of this disease cannot possibly be doubted by
any medical man who in his practice has seen much of children's
complaints, or of institutions of which a large number of children, or
even of adults, are inmates. In foundling and orphan institutions,
in nursing establishments, children's hospitals and boarding schools,
and also in workshops, manufactories, hospitals, and prisons, one
has abundant and lamentable evidence of the infectious nature of
scarlatina.

Confining myself, in the first place, to my own experience, I
may say that I have often enough had occasion to observe that one

218 SCARLATINA (MAYR).

child suffering from scarlatina and placed in a children's hospital
among other patients has soon infected half of them with this disease,
which, perhaps, was not at the time prevalent in an epidemic form.
If, under these circumstances, the cases of scarlatina are not at once
isolated, the complaint may not subside for years, being kept in a
stationary condition by the constant admission of fresh children into
the institution.

What I have just stated with regard to hospitals for the sick is
true also when applied to separate families, or to particular towns or
districts, although many circumstances combine to make it difficult
of proof. The transference of the disease from family to family, or
even from one locality to another, may often be clearly traced, and
can be satisfactorily explained only by admitting that scarlatina is
infectious. According to trustworthy writers (Duncombe, Noirot),
it has been proved that this complaint has been introduced by
strangers into certain islands, such as the Bahamas and the Antilles,
in which it had never prevailed, at any rate within the memory of
the inhabitants.

The most conclusive evidence of the contagious nature of this
disease would certainly be its direct propagation by the transference
of some inoculable matter from one individual to another. Unfor-
tunately, the experiments which I have made with children suffering
from scarlatina have not hitherto been attended with the same success
as in the case of measles.

In my opinion, then, this complaint is always produced by a
specific contagious principle; I do not believe that it ever arises
spontaneously, any more than smallpox, measles, or syphilis. It is
true that the conditions necessary for the development and diffusion
of the exanthemata are far more difficult to determine than is the
case with syphilis ; but this is no reason for doubting that we
shall hereafter discover the cause of the infectious character of these
diseases. Indeed^ formerly, when the cause of scabies was unknown,
even that affection was supposed to be of spontaneous origin, till at
last the finding of the acarus removed all doubt as to its contagious
nature. Moreover, it is certain that, since the first appearance of
the exanthemata, the complete and universal extinction of any one of
them has never occurred. In the case of scarlatina, we have, in the
registers of deaths, a sufficient proof that in Yienna this disease has
never absolutely died out during the course of the last fifty years.
Even when it has not prevailed epidemically to a marked extent.

DIAGNOSIS. 219

it has always existed iu a sporadic form in some or other of the
suburbs or outskirts, being sometimes most prevalent in the higher
parts of the city, while at other times it affects chiefly those which
are at a lower level. So also the official reports of epidemics in the
province of Lower Austria prove that the disease has always been
present sporadically in one part of the country or another, and that
it has not in any year been completely absent.

Now this fact, if established beyond dispute, is in itself a sufficient
ground for inferring the presence of a contagious principle which
always exists, but is under some circumstances restricted to
certain localities, while under other conditions it becomes more
widely diffused. It is true that we are not as yet able to say what
these conditions are, and that we can only take refuge in vague
expressions, referring them to causes with which we are still imper-
fectly acquainted ; such as variations in temperature, or in the amount
of moisture present in the air ; states of the weather ; barometric or
thermometric changes ; telluric or cosmical influences, &c.

As a rule, scarlatina attacks the individual once only in the course
of his life. Indeed, during the most severe epidemics I have never
in a single instance seen either a child or an adult who had already
passed through the disease affected with it for the second time, even
among persons who have associated freely with patients suffering
from scarlatina.

What is the nature of the contagious principle of scarlatina?
What are its properties ? During what stage of the disease is it
developed ? In which period is this complaint most highly con-
tagious ? — These questions, although frequently asked, have never
yet been completely answered. Being myself unable to explain these
points fully, and being very averse to dealing with hypotheses, I
will confess my ignorance rather than attempt " ohscura olscurioribus
dilucidare."

Diagnosis of Scarlatina.

The presence of a red rash upon the skin does not in itself
warrant the assumption that the case is one of scarlatina ; to justify
such a conclusion, the rash must be accompanied by fever and an
inflammatory affection of the tliroat, and must be followed by
desquamation. The diagnostic signs of this exanthem are these :
the existence of a special efflorescence; its mode of distribution

220 SCARLATINA (MAYR).

over the cutaneous surface ; the inflamed state of the parts concerned
in deglutition ; the peculiar desquamation ; the spreading of the
disease by contagion ; its epidemic occurrence ; the febrile symptoms
which accompany it ; and, lastly, the sequelae to M'hich it gives
rise.

In some instances, a large number of these characters are present ;
in others, only one or two of them. In the former case, the recog-
nition of scarlatina is easy ; in the latter case, it may be very difficult.
Indeed, it may happen that the contagiousness of the disease is the
only proof of its nature, or that we cannot make a diagnosis till
we have watched the course of the case for a considerable time, or
even till it has passed into the stadium desquamationis.

The principal cutaneous afTections with which scarlatina can be
confounded are the following : —

1. Erythema. — Under this head, I here include all those morbid
reddenings of the skin which, when generally diffused, are termed
erythemata, but which, when they present distinct maculae, receive
the name of roseola. They are generally unattended with fever ;
and any febrile symptoms which may be present are due to some
other disease. Moreover, these rashes are very irregular in their
mode of invasion, in their distribution over the cutaneous surface,
and in their duration ; their different stages occupy but a very short
space of time ; they are not followed by desquamation, and are not
contagious.

2. The distinctions between measles and scarlatina may be best
displayed in a tabular form : —

Morbilli. Scarlatina.

A. In the Stadium Pkodromoeum,

There is a catarrhal inflammation of The parts principally inflamed are
the lining of the respiratory tract, in- those concerned in deglutition, namely,
eluding the Schneiderian membrane, the tonsils, soft palate, and fauces,
the mucous surface of the larynx and
trachea, the palpebral conjunctiva, &c.

As a result of these afi'ections, the Hence the chief symptoms are dif-

patient suffers from a cold and cough, ficulty of swallowing and consensual
and from epistaxis and intolerance of (consensuelles) vomiting, with swelling
light : his eyes are red, and there is of the sides of the neck,
swelling of the face, round the mouth,
nose, and eyes.

DIAGNOSIS.

221

Morbilli.

The fever is less intense ; the pulse
between loo and 120; the tempera-
ture of the skin moderate.

Tlie duration of this stage is from
three to five davs.

Scarlatina.

The fever is intense; the pulse
between 120 and 140; the tempera-
ture of the skin much above the
normal height.

The duration is not more than one
or two days.

B, In the Stadium Erupxionis,

The efflorescence appears first on
the face, and slowly spreads over the
trunk and limbs, its diffusion occupy-
ing on an average thirty-six hours.

The fever and the catarrhal symp-
toms persist in about the same degree
of intensity.

The eruption breaks out on the
neck and upper part of the chest, and
diffuses itself rapidly (within eighteen
hours) over the other parts of the
body.

The fever and the anginal symp-
toms acquire increased severity.

c. In the Stadium; Flokitionis,

The maculse are of the size of the
finger-nail, of an irregular form, and
of a colour varying from yellow to a
brownish red, and are separated from
one another by tracts of healthy skin.
They are most abundant on the face
and trunk, but more scanty on the
limbs, and particularly on the palms of
the hands and soles of the feet. They
often take the form of papular eleva-
tions, due to a swelling of the orifices
of the hair-sacs.

The only subjective sensation is a
feeling of slight tension and heat in
the skin.

During the second half of this stage
the fever and other concomitant symp-
toms diminish in intensity.

The duration of this period is from
three to four days.

The rash consists of red })atches, at
least as large as the palm of the hand,
or, still more generally, covers the
whole surface of the body without in-
terruption. It is of a scarlet colour, or
presents a slight tinge of blue. Its
greatest intensity is on the neck and
chest ; but it is not much less fully
developed on the extremities, or on
the hands and feet. The face is
generally free from it.

The patient feels a more or lesa
intense burning sensation in the skin.

The fever and other concomitant
symptoms persist, throughout the
whole of this stage, without diminu-
tion.

The duration of this period is from
two to six days.

D. In the Stadium Desquamationis,

The desquamation is furfuraceous, The desquamation consists in the

extending to different parts of the separation of large membranous pieces;
body in anatomical order. There is, the part also assumes a yellow colour.

323 SCARLATINA (MAYR).

Morbilli. Scarlatina.

at the same time, a considerable de- The desquamation is most marked on
position of pigment. the hands and feet, while the yellow-

tinge is most obvious on the face and
trunk.

The sequelce of morUlli consist The principal sequelce of scarlatina

chiefly in inflammatory diseases of the are, inflammatory affections of the
respiratory organs, and in diphtheritic glands and areolar tissue, dropsy of
or gangrenous affections. the subcutaneous connective tissue

and serous cavities, and, lastly, albu-
minuria.

3. Another eruption which may be mistaken for scarlatina is
3Iiliaria, especially that form of it which has been termed M. rubra,
and which is^ I think^ identical with the affection known as sudamina.
The only cases in which this mistake can occur are, however, those
in which the ordinary scarlatinal rash is combined with a miliary
eruption^ or with sudamina ; and, even then, the exanthem presents
so many characters which are altogether wanting in every form of
miliaria, that an error is scarcely possible. Further details will,
however, be given under the head of Miliaria.

Treatment of Scarlatina.

Medicines have been employed against scarlatina for two distinct
purposes : ürst, in the hope of protecting the organism against the
contagion of this complaint ; secondly, with the object of counter-
acting the disease itself in its irregular forms. I have, therefore,
to speak of \)üs. prophylactic as well as of the curative treatment of
scarlatina.

Por the purpose of warding oft' an attack of this disease, medical
men have proposed all sorts of prophylactic measures, and have
administered medicines of every kind : unfortunately, these have
always, within a very short time, turned out to be perfectly useless.
The older physicians had great confidence in the mineral acids, and
the hydrochloric acid has recently been vaunted as a prophy-
lactic by Godelle. Hufeland and Hahnemann ascribed to belladonna
a protective influence against scarlatina; hydropathic practitioners
have recommended the daily use of cold ablutions ; Webster advised

TKEATMENT. 233

that the body should be washed with dilute vinegar ; Dehne, that
inunction with oil should be practised.

At the present time, however, there is probably scarcely a single
hospital physician or practitioner of experience, who sets much
value upon any one of the prophylactic measures which I have
mentioned. We beHeve, then, that the only effectual prophylaxis of
scarlatina consists in isolating the patients from those who are
unaffected, as early and as completely as possible.

As for the curative treatment (in the narrower sense of the word),
the jiitifn desiderium to possess a remedy which should neutraHse the
scarlatinal virus formerly led persons to employ emetics, the so-called
antimiasmatic and diaphoretic agents (such as chlorine, acetic acid,
carbonate of ammonia), irritants applied to the cutaneous surface,
the antiphlogistic method (vensesection and calomel), and, lastly,
the cold-water cure, and even rubbing the surface of the body
with bacon. Each one of these therapeutic measures, however,
proved to be either inert, or rather injurious than useful.

In my opinion, therefore, and according to my experience, we
have not yet succeeded in discovering any specific remedy for scar-
latina, nor in establishing any exclusive method of effecting a cure
of this disease. But I am far from saying that we are to put our
hands in our pockets, and leave the complaint to run its course
without interference.

Por, although we possess no antidote to the contagious principle,
we nevertheless have remedies to counteract its destructive effects.
The treatment, therefore, should always be of a symptomatic kind,
and directed mainly against those complications and sequelse which
disturb the regular progress of the disease.

In cases in which scarlatina is uncomplicated, and the fever and
angina slight, and in which there are no other symptoms to cause
anxiety, no medicinal treatment is necessary ; all that need be done
is to give the patient cooling acid drinks, to administer small doses
of one of the vegetable or mineral acids, and to direct the proper
hygienic measures to be carried out.

Perhaps it may not be superfluous for me to describe, in detail,
the instructions which I am in the habit of giving for the manage-
ment of patients affected with scarlatina.

1. Cool, refreshing drinks (such as cold spring water, lemonade,
water to which the juice of some acid fruit has been added, &c.)
are to be given freely and at short intervals. These drinks are very

224 SCARLATINA (mAYR).

acceptable to the patient^ and fulfil the indications afforded by the
presence of fever, and of affections of the mucous membranes
and digestive tract, far better than the tepid, and often heating,
mucilaginous fluids which were formerly administered.

2. The diet should consist of weak meat broth or gruel, with
milk, and fruits which have been cooked.

3. The air should be changed at least twice a day, and should be
kept cool rather than warm, its temperature never being permitted
to exceed 66° Fahr. The sick-room should not be allowed to be
crowded, the persons required to nurse the patient, and to attend to
his wants, being alone let to remain in it.

4. The patient should keep his bed, but the coverings over him
should be only just warm enough to prevent his feeling cold.
Peather beds and heavy coverlets must, as far as possible, be avoided ;
and movable screens round the bed should be taken away, because
they interfere with the due circulation of the air.

5. The ordinary habits of cleanliness are never to be neglected ;
the bed- and body-linen may be changed as often as necessary, and
the patient^s hair may be combed every day, and his face and hands
Washed with soap and water.

6. A person suffering from scarlatina should not be allowed to
leave his bed until, for two or three days, the excessive thirst has
disappeared, the skin has been soft and perspiring, and the pulse in
its normal condition.

7. After the termination of the sladium desquamationis — that is,
about the end of the third week (supposing the disease to run the
usual course) — the patient may be ordered to take a tepid bath
every third day.

8. As soon as desquamation has passed off from the hands and
feet, as well as from the face — that is, at the commencement of the
fourth week from the first appearance of the rash — the patient may
be dismissed from further treatment, and allowed to go out in the
open air — unless, indeed, any fresh symptoms should arise to prevent
this being done. The ordinary term of six weeks is unnecessarily
long in many cases in which scarlatina takes a normal course ; while,
on the other hand, wben complications are present, it is often not
sufficient to allow of the subsidence of all the symptoms of the disease.

In tlie medicinal treatment, I purposely avoid giving either dia-
phoretics or purgatives ; — the former, because, without any object,
they increase the congestion of the skin ; the latter, because they

TREATMENT. 225

needlessly irritate the intestinal surface, already in a morbid
condition.

I cannot refrain from insisting, for the second time, on the fact
that, in diseases which have to pass through a typical course, and
are attended with a more or less regular series of symptoms — among
which diseases all the exanthemata (and, of course, scarlatina) are
included — we must look rather to hygienic measures than to the
administration of medicine. The simpler the treatment, the more
easily does nature bring about the cure for which we hope. Hence,
in cases of scarlatina which run a regular course I prefer the
" expectant method," combined with proper hygienic management,
to every kind of active interference by means of medicines.

On the other hand, if complications arise, whether at the very
commencement of the disease or during its course, we must
prescribe those remedies which check the progress of these secondary
affections, or remove them, or at least diminish their severity, when
they have already developed themselves.^

In the treatment of the angina nothing succeeds better than giving
the patient ice-cold water, or small pieces of ice, night and day,
without interruption, till the swelling of the fauces has subsided and
the pain during deglutition and the other symptoms have disap-
peared. Should the enlargement of the tonsils increase rapidly, nitrate
of silver, either in the solid form or in solution, may be applied with
great advantage ; and the other measures usually carried out under
such circumstances must be adopted.

In consequence of its rapid course, we are altogether powerless
against that form of scarlatina which I have attributed to a dissolution
of the blood. None of the remedies which have been proposed (in-
cluding camphor, musk, the application of blisters^ the abstraction of
blood, and the cold-water cure) are able either to check its progress
or to prevent its terminating fatally. It is, however, as well to endea-
vour to alleviate the symptoms by the employment of cold affusions,
frictions, '^packing" in wet sheets, and cold applications to the
head, or to use the remedies generally prescribed in typhus, such

1 The description of the symptoms of the complications and sequelae of scar-
latina having been omitted in the translation, the details of their treatment
are also left out. The few remarks which follow have been retained, because
they seemed of some importance, or because the practice recommended differs
somewhat from that usually adopted iu this country. — [Ed.]

226 SCARLATINA (MAYR).

as quinine, acid drinks, or even opium and morphia, iufusum
ipecacuanhse, &c.

We possess no specific remedy for the consecutive dropsy any more
than for scarlatina itself. In children who obstinately refuse to
take medicine, and in patients who are treated homoeopathically or
hydropathically, we often observe that nature, without medical aid,
effects the removal of dropsical accumulatious by abundant perspira-
tion and diuresis. It is our business, therefore, to assist the efforts
of nature, at the right time and in the proper way, and not to
check them, in our impatience, by continually giving drugs, and
repeatedly changing our prescriptions. In this instance, again, the
maxim holds good that the more simple the treatment the more
certain is its success.

The first question that suggests itself is whether we can, by the
use of suitable remedies, prevent the occurrence of dropsy when its
approach is already indicated by the presence of albuminuria or
other unequivocal symptoms.

In my opinion, we can succeed in doing this only when the
effusion takes place slowly, and is unattended by the symptoms of
inflammatory afi'ections of internal organs. Under such circum-
stances, if the patient is of good constitution, we should confine
him to a strict diet, and prescribe gentle laxatives and the use of
baths and cold ablutions; whereas to anaemic persons we should
give nourishing and easily digestible food, and the preparations
of iron and quinine. By these means, if we do not altogether prevent
the occurrence of dropsy, we shall, at any rate, very greatly check it.

As is the case with the other complications of this exanthem, the
treatment of albuminuria and its effects must be based on the same
principles which guide us in the management of such complaints
when independent of scarlatina.

In conclusion, I may say a few words concerning the specific
methods of treating scarlatina which have been advocated by physi-
cians and by unprofessional persons. I refer to the use of cold
water for the cure of this disease, and to Schneemannes plan of rub-
bing the surface of the body with bacon.

The treatment by cold water was recommended, long since, by
Bateman, and has recently been carried out by the hydro-therapeu-
tists. It includes the use of cold affusion, " pacTcing" in cold wet
sheets, and cold ablutions. With regard to the manner hi which
aftision should be practised, the rules laid down by Curie are still

TREATMENT. 227

the most complete which have been given, and are just the same
as the procedures adopted by the modern hydropaths. Curie
made the patient sit in an empty tub, and poured over his head four
or five gallons of cold water, so as to wet his whole body. This
treatment was commenced soon after the eruption first appeared, and
was repeated as often as the skin became hot and dry, generally
from six to twelve times daily. At the same time acid cooling
drinks were given. After each afPusion the patient, having been
dried, was at once put into bed and left to himself.

The " jmcHngs" are carried out on the Gräfenberg plan. They
are used indiscriminately in all cases, with the object of inducing
free perspiration rather than for the pm-pose of cooling the skin.
One or two large sheets are first dipped in water and well wrung
out ; the patient is then wrapped in them from the chin downwards,
the head, vrith the exception of the face, being afterwards enveloped
in wet napkins, outside which, lastly, ice (Eisumschläge) is applied
if intense congestion is present. He remains thus packed up from
two to four hours, during which time cold water is given him to
di-ink. At the end of this period the patient, now in a state of
profuse perspiration, is again made to take a cold bath, or has cold
water poured over him. This procedure is repeated at least twice
daily, or even still more often, particularly if the skin is very hot and
dry.

The third method of employing cold water, that of ablution, is
more generally applicable than either of those which I have been
describing, and is attended with less difficulty in practice, while it
yet accomplishes the object aimed at. It consists simply in washing
the patient with sponges dipped in cold water, after which his skin
is well rubbed with pieces of flannel^ this procedure being repeated
as often as the heat and dryness of the surface increase. Tepid
water instead of cold may be used for this purpose, should it be
more agreeable to the patient.

It appears to me, however, that in many cases (especially among
children, who form the majority of scarlatinal patients) the systematic
application of cold water would not be well borne, and would be
difficult to manage. Indeed, I think it would be positively injurious
in many of the affections which accompany this exanthem, and par-
ticularly in diseases of the circulatory or respiratory organs, in which
complaints a sudden excitement might prove immediately fatal. At
auv rate, medical men should take into consideration the condition

238 SCARLATINA (MAYR).

of the patient and the other circumstances of the case, before enter-
ing upon such an heroic plan of treatment.

The method recently proposed by Schneemann, of curing scarlatina
by rubbing the surface of the body with bacon, is allied to the plan
recommended by Dehne in 1810, of anointing the skin with oil.
Each of these authors was led to suggest the practice of inunction
by the idea that in scarlatina the principal danger to the patieiit
arises from the functions of the skin being interfered with by the
disease in the same way as they are by extensive burns. It was
supposed that rubbing oily or fatty substances into the cutaneous
surface would preserve the integrity of the diseased organ, and pre-
vent the occurrence of any secondary affection due to disturbance of
the skin's action.

The directions for the carrying out of this method are as follows :
—A piece of bacon, as big as the palm of the hand, and with the
rind still attached, so as to make it easier to hold, is to be taken,
and several cuts are to be made on its under surface. It is then to
be vigorously rubbed over the whole of the patient's body, with the
exception of the face and head, the application being commenced
from the very first day of the disease, and repeated at least twice
daily, in the morning and evening. Excepting the part which is
actually being rubbed, the body of the patient must not be exposed
during this treatment. The linen is not to be too often changed,
and no water is to be allowed to touch the skin. The patient is to
be kept in a moderately cool atmosphere, at a temperature of 61°
Eahr. He is to remain in bed as short a time as possible, and to be
limited to a sick diet only during the presence of fever, being
allowed to go into the open air by the tenth day, reckoned from the
beginning of the disease. The inunctions are, however, to be con-
tinued for full three weeks, without interruption, after which the use
of warm baths is recommended.

It was Schneemannes opinion that by this procedure the disease is
made to terminate with the disappearance of the rash, and that no
desquamation occurs.

Although this mode of treatment has already undergone sentence
of oblivion, and there have been very few who, like Mauthner and
Illisch, have carried it into practice, yet I may, in this place, report
the results of my own trials of it. I have carefully followed
Schneemannes directions in the treatment of twenty children affected
with scarlatina ; but I regret to say that I have not seen those good

TREATMENT. 229

effects which his laudatory statements had led me to expect. The
procedure in question certainly did not prevent the appearance
of complications^ for in two of these patients angina gangrenosa set
in ; in one^ diphtheritis ; in two, pneumonia ; and in two, dropsy.
Nor did I find that this method checked the spreading of the
disease by contagion, nor that it prevented the occurrence of desqua-
mation. On the other hand, it is not to be denied that in some
cases this treatment relieved the troublesome itching and burning
sensations complained of by the patient, and that it removed the
dryness and heat of the skin, and made it disposed to perspire. In
fact, the benefit derived from rubbing the patient's skin with bacon is
very similar to that of ablution with cold water.

CHAPTER X.

VAEIOLA.

TEBEIS VARIOLOSA, BLATTERN, POCKEN. PETITE VERÖLE,

SMALLPOX, VAJUOLO.
(CLASS IV.— ACUTE EXUDATIVE CONTAGIOUS DERMATOSES.)

Literature of Variola.

Avicenna, 'Liber canonis de Medicinis cordial./ Venetiis, 1662. —
Ithazes, 'De Variolis et Morbillis/ Londini, 1766 (S^'d. Soc. Trans.,
Lond., 1848). — Sydenham, 'Opera/ sect. 3, edit. Batav., 1700
(Syd. Soc, 1844). — R. Morion, 'Pyretologia/ Amstelodami, 1699. —
Mead, ' De Variolis et Morbillis liber/ 1747. — Rnxham, vol. ii. — Van
Swieten, ' Commeutaria in H. Boerhaave Apliorisnios/ torn, v, Lugd.
Bat.j 1772. — Cotugno (Cotumiius), 'De Sedibus Variol. Syntagma/
177 1. — Borsieri (Burserius), ' Institutiones Med. Pract.' — BeHaen,
* Abhandlung von der sichersten Heilart der natürlichen Pocken/
Wien, 1775. — Beter Frank, 'De Curandis hominum Morbis/ Ticinse,
1792, § 329. — Friedr. Hoffman7i, 'Opera omnia Physico-medica/
Genev£E, 1740. — Joh. Storch, 'Abhandlung von Blatternkrank-
heiten/ Eisenach, 1753. — C. L. ^0/^?>/ßWÄ ' Abhandlung von den
Pocken/ Münster u. Hamm., 1770. — Sauvages [F. Boissier de),
' Nosologia Meth.,' t. i, p. 422, Amst., 1748. — Muhry, ' Hufeland's
Journal,' vol. xxviii, p. 1, and vol. xxx, p. 128. — Stieglitz, 'Horn's
Archiv/ xi, p. 187. — Betzholdt, 'Die Pockenkrankheit mit beson-
derer Eücksicht auf die path. Anatomie/ 1836. — Rilliet etBarthez,
1 843, ii, p. 430. — Gregory, ' Lectures on the Eruptive Pevers,' 1 843.
— Williams, 'Elements of Medicine,^ 1826,1, 192;^ — Eimer {Chr. H.),
'Die Blatternkrankheit in path. u. Sanitätspolizeilicher Beziehung/
&c., Leipzig, i853.-7-Consult, lastly, the works of the weU-known
dermatologists Willan, Bateman, Alibert, Bayer, Cazenave, v. Schedel,
Gihert, Bevergie, Fuchs, Simon, &c.

According to certain manuscripts preserved in the British Museum,

VARIOLA. 231

whicli date from before the year 900 a.d.^ and in which [the word
Variola is repeatedly employed, the name applied at the present day
to this disease seems to have been in use even before the time of
Constantius Africanus, who is stated to have been the first physician
acquainted with this affection^ and to have given to it the name of
Variola. It is, however, incontestable that this disease is of such
extreme antiquity that the medical historian in vain attempts to fix
the time of its first appearance. According to Moore, it existed in
China and Hindostan even before the age of Hippocrates. Others,
among whom are Freind, Mead, and Gregory, think that the earliest
notice of this complaint is to be found in the writings of Pro-
copius (a.D. 544). Bryce traces the first appearance of smallpox
to the year 532, when it is said to have prevailed in the countries
bordering upon the Red Sea. The earliest descriptions, however,
which can be with certainty referred to this disease are those of the
Arabian school, and particularly of Rhazes, a.d. 910.

It is said by some that the name Variola was coined by the monks,
who, during the middle ages, were, as is well known, the representa-
tives of learning, from the Latin word varus (a papule, pimple, or
tubercle), which is to be found in Pliny. Others, however, derive
this term from the Greek word aioXog {varius, variegatus). The
German Pocke means a bag or pouch.

When, at the end of the fifteenth century, syphilis was recognised,
a disease of which the eruption in some cases resembles that of
variola, it became necessary to have some means of distinguishing
these affections from one another. This is the origin of the English
term smallpox, and of the French expression la 2^ elite veröle.

All medical and also all lay writers upon variola have known
that this disease is contagious. But the slight intercourse which
formerly existed between different nations explains the fact that
smallpox did not spread to any great extent before the eleventh
century. Indeed, the most powerful agent in difi'using this disease
was the Crusades, in the eleventh, twelfth, and thirteenth centuries ;
and during these wars it was brought from the East to the West.
Its first appearance in Germany is referred to the year 1493, """^^^^
it is stated to have been introduced from the Netherlands by the
soldiers of the Emperor Maximihan I. After that time small-
pox spread pretty rapidly, both in Europe and in America, and in
these quarters of the globe claimed its victims by millions.

Certain epidemics, however, were found to have a benign character.

232 VAEIOLA.

and even in others some individual cases ran a favorable course.
Hence, in the course of the eighteenth century the idea suggested
itself to physicians that these mild epidemics and cases of smallpox
might be employed to generate artificially a similar form of the dis-
ease in persons who had as yet escaped it : and this was the origin
of the practice of inoculating variola. Eimer and others do, indeed,
state that this operation was used in China, Circassia, and Africa, as
far back as the eleventh century. But, in my belief, the earliest
ascertained fact in the history of this practice is that in the year
1 718 Lady Mary Wortley Montague, the wife of the English
ambassador at Constantinople, allowed herself to be inoculated in
that city with smallpox matter taken from the human subject. By
this lady the practice was also introduced into England. From this
country the method of protection against variola by inoculation
spread to other parts of Europe; but met with only partial acceptance,
for epidemics occurred as frequently as before, and the disease was,
in fact, carried by it to certain regions in which it had previously not
existed, or had but seldom shown itself. Hence, as the eighteenth
century advanced, the practice of inoculating with the smallpox virus
became less and less common, and at last it was forbidden in most
countries, because statistical evidence showed that in spite of it
more than half a million persons died annually in Europe from
variola.

When we reflect on this great mortality we begin to appreciate at
its right value Jenner^s beneficent discovery of the protecting in-
fluence of the cowpox against variola. This discovery is, indeed,
ascribed by some authors, not to Jenner, but to others, namely,
either to Plett, of Holstein, a schoolmaster, or to Eabaut-Pommier,
of Montpellier, a Protestant clergyman, in 1781, or, lastly, to Sutton
and Eewster (who were inoculators of smallpox) in 1768. But to
Jenner belongs undoubtedly the merit of having given incontro-
vertible proofs, not only of the prophylactic power, but also of the
practical applicability, of vaccination.

Even since the introduction of this operation epidemics of variola
have still appeared, although more rarely, and in a milder form than
before. Hence those who maintain that the cow-pox affords an
absolute protection have been led to suppose that there are other
pustular diseases resembling smallpox very closely, but not identical
with it. Moreau de Jonnes, in particular, held that the varioloids
constitute an independent affection, which is quite distinct from

VARIOLA. 233

smallpox, and against which vaccination affords no security.
Dufan, Dubois, Paradis, Ebers, Neurohr, Küster, Strecker, and
others, have adopted the same opinion. Again, varicella, which was
first described by Heberden in the year 1766, has since the intro-
duction of vaccination been asserted to be a form of variola, modified
by that operation. It has, however, already been made apparent,
as was even shown by De Haen as far back as 1775, that this dis-
ease existed long before the time of Jenner's discovery, and that its
course was as mild tlien as it has been since the adoption of vacci-
nation. The controversy whether variola is a single malady, pre-
senting three different forms, or whether there exist two or three
more or less similar pustular diseases, could only be settled by the
production of evidence to show whether these affections are produced
by one contagious principle only or by several.

It will have escaped no medical man who has had much oppor-
tunity of observing smallpox, that when several persons fall ill at
the same time in one family, or even in one locality, the severity of
the disease and the extent of the eruption vary greatly in different
cases. In fact, we see in every epidemic instances of varioloid and
varicella,^ as well as of true variola. Hence the question may
fairly be raised, " What contagious principle is it which, in these
cases, generates the disease ?" To be consistent, it would be neces-
sary to admit the existence of more than one epidemic ; to assume,
in fact, the prevalence of varicella at the same time with smallpox and
its modification, the varioloid. No experienced practical physician,
however, would entertain this notion. Indeed, there is positive
proof that varicella may generate variola or varioloid, and that,
conversely, variola may produce, in another individual, varicella,
independently of any influence due to previous vaccination. I

» With reference to the statements which follow, it must be borne in mind
by the English reader that Prof. Hebra's definilion of varicella is entirely dif-
ferent from tiiat to which we in this country are accustomed. By varicella, he
simply understands a very mild form of smallpox, although it is at the same
time true that he altogether disbelieves in there beiug any distinct disease,
such as we suppose to exist and term varicella. Tor this reason, the criticism
on Prof. Hebra's views, by Dr. Gee, in the 'System of Medicine' (1866, vol. i,
p. 520) seems to me wide of the mark. Prof. Hebra denies that there is a
separate disease such as we call varicella and, basiiles the cases to which we
should give this name, lie iucludeis all cases of very niiid sninllpox under llie
same head, applying to them colleciively the name vadceilaj and then he

234 VARIOLA.

have every year occasion to observe^ that VThen a case of smallpox in
any of its varieties presents itseK in my medical cKnique, several of
the students, both vaccinated and unvacciuated, who come into con-
tact with the patient, are attacked by the disease, and that under such
circumstances the form which makes its appearance is by no means
always the same as in the original case.

In the General Hospital at Vienna, it sometimes happens that a
person affected with variola or varicella is placed by accident
among other patients in a room not specially devoted to these cases,
and remains there for a few hours, or tiU the next day. This is
often quite sufficient to infect one or more of those who, being ill of
other diseases, lie in the same ward ; and under these circumstances
we often see several bad cases of variola vera generated by a patient
affected only with a mild varicella. We have a still more striking
proof of the same fact when the smallpox contagion is introduced
among the newly born infants and children at the breast in the
Toundling Hospital of this city. Por we find that when this occurs
cases of varicella and of variola vera make their appearance simul-
taneously, the former running a favorable, the latter an unfavor-
able course. The same thing is also taught us by the history of the
inoculation of variola. For this purpose, no one used lymph taken
from cases of variola vera ; the contents of tJie vesicles of varicella,
the mildest form of the disease, were certainly always employed^
in order to prevent evil consequences. This surely is a proof that
varicella has, within the memory of man, been the source of devas-
tating epidemics of variola.

It may be inferred from what I have said that I believe variola
to be one disease, and not to include two or three different
maladies, though, like any other complaint, it may of course
present different degrees of intensity. I apply, then, the name
variola vera to the most severe form of this disease, that in
which the eruption is abundant and the fever intense, and in A^liich
a fatal result is often observed. On the other hand, I use the term
varicella for cases in wliich the rash is very scanty, and which run a
favorable course, and always terminate in recovery. Between these

says that such cases generate smallpox. To which it might be answered
that, without doubt, some of the cases which Prof. Hebra calls varicella may
propagate smallpox, but that it still remains a question whether such cases
as would be called varicella here can do so. — [Ed,]

VARIOLA. 235

extremes lies the varioloid as a middle term^ presenting an eruption
moderate in amount, a course which is generally mild, and a success-
ful issue.

The fact that the patient has previously been vaccinated does not
at all influence me in applying one of these names rather than
another to a particular case. Por I have observed severe con-
fluent smallpox, variola vera, in those who have been vaccinated ;
while, on the other hand, in newly born children who have not been
vaccinated the disease sometimes takes its most mild and favorable
course, so as to constitute what I term varicella.

Again, I cannot admit that any anatomical characters (such as the
umbüicus, the cellulated structure, or the so-called pseudo-mem-
brane of the pustules) are, as has been asserted by some, charac-
teristic of true smallpox ; nor do I regard the secondary fever, which
has likewise been stated to occur only in the variola vera, as belong-
ing to that form of the disease alone.

Por if we, on the one hand, consider that the epidermis is a line
in thickness, and consists of many layers, placed the one above the
other, and that the fluid which gives rise to the smallpox vesicle is
poured forth either by the vessels of the papillte or by those
which supply the follicles, and if we further trace attentively the
development of the pustules themselves, we shall find that their
anatomical structure is altogether difierent from that ordinarily sup-
posed.

Thus, if we make either a vertical or a horizontal section of a
variolous papule in the earhest stage, the summit of this papule is
always found to consist simply of the most superficial stratum of
the epidermis, having on its under surface a few softened epidermic
layers of more recent formation. The contents at this time appear
as a fluid presenting either no formed elements or only a small
number of young epidermic cells, with a few pus-globules and blood-
discs. If this operation is repeated on a vesicle which has under-
gone further development, the anatomical appearances are the
same; or, at any rate, the only difference is that the number
of pus-cells is found to be greater each day as the age of the
vesicle increases. In no case do we discover any other patho-
logical product, either adhering to the under surface of the roof of
the papule or vesicle, or contained within its interior. The epidermic
covering of one of these papules or vesicles, when cut ofl" horizon-
tally and placed beneath a low power of the microscope, is seen to

236 VARIOLA.

be either discoid or of an annular form, according as its centre is or
is not perforated by a hair. It is, therefore, at once obvious that
smallpox pustules develope themselves both round the mouths of the
hair-sacs and also in the interfoUicular spaces. When the small-
pox papule has passed into a fully developed vesicle, this will yield
only part of its contents when pricked on one side and subjected to
pressure. The whole of the contained fluid can be evacuated only
by removing the roof of the vesicle or by puncturing it laterally at
several points. This fact, indeed, has long been known, and in
the case of the vaccine vesicle has often been turned to practical
account. It was this which gave rise to the notion that the small-
pox or vaccine vesicle contains in its interior a number of dissepi-
ments by which its cavity is divided into as many chambers. Any
one may, however, convince himself that this is not the case by
cutting off one half of a vesicle and raising it with a pair of
forceps. Under these circumstances the separate compartments
would, of course, be seen, if they existed. I think, however, that I
can account in quite a different way for the fact that the contents
of the vesicle are only partially evacuated when a lateral puncture is
made, and that I shall be able at the same time to explain the
development of the umbilicus and the nature of the so-called
pseudo-membrane.

We have seen that when the smallpox eruption begins to make its
appearance a fluid is poured out either by the vessels of the papillae
or by those of the follicles. This fluid, which may be termed a
blastema, an intercellular fluid, or an exudation, appears as a minute
drop. It is on all sides met by the epidermis, and, as I have
already fully explained,^ is compelled to permeate the substance of
this tissue. Now, if the vispremens a tergo should continue to urge
this drop of fluid forwards, it will, after traversing the different
softer layers of the cuticle, at last reach the external horny stratum.
This, being less capable of imbibition, will oppose to the fluid a
greater resistance, and, therefore, will become raised above the sur-
face, so as to form a papule, which will afterwards (when the exuda-
tion has increased in quantity) pass into a vesicle.

Now, if the fluid be poured forth by the vessels of a papilla into
an interfoUicular space, the papule (and afterwards the vesicle) will
be semiglobular in form, and will present no central depression.

* See the footnote to p. 7.

VARIOLA. 237

But if, on the other hand^ vessels supplying a hair- sac yield the
formative material, this wiU penetrate directly the layers of epidermis
lining the sac and forming the root-sheath of the hair, and will
thus cause a swelling of this substance. Now, that part of the root-
sheath which immediately surrounds the hair receives support from
it ; whereas the external root-sheath, which comes next in order, is
less firmly adherent, and will first be detached by the effused fluid.
Hence these outer layers will become raised above the surface of the
skin more than the central one, and will form round the hair an
elevated ring, which can be plainly recognised, even on the first
appearance of the eruption, when it is still papular. As the quantity
of fluid augments, and the papule becomes a vesicle, this ring also
will increase in size ; and even when the contents have accumulated
to such a degree as to raise the centre of the vesicle also above the
level of the skin, there will still remain indications of the original
funnel-shaped depression, which will then, in fact, form the umbilicus.
Now, I have already shown that whether a smallpox papule is or is
not developed round the mouth of a hair-sac, the epidermis is in any
case the recipient of the exudation which is poured out ; hence the
vesicle never consists of a simple cavity, filled with liquid contents,
but is always made up of a mass of epidermic cells, infiliratecl with
an exuded fluid. The difi'erent strata are, indeed, so loosened by
the exudation that their texture might be compared to that of a
grape (in which we find the juice infiltrating the vegetable tissue in
a similar manner), or of the substance which is named by Yirchow
the mucous tissue, and of which we have examples in the vitreous
body and in the jelly of Wharton. This explanation enables us to
understand why, when one side of a smallpox pustule is punctured,
only a part of the fluid escapes, so much of it, in fact, as is
mechanically pressed out from the epidermic layers immediately
adjacent to the track of the puncture. The supposed cellulated
structure of these pustules, in fact, turns out to be merely the result
of the infiltration of the different strata of the cuticle with the fluid.
That this is a correct explanation is proved by the fact that the
umbilicus is to be seen, not in smallpox only, but in all other
cutaneous diseases in which vesicles and pustules are developed,
provided only that the anatomical conditions and the mode of origin
of the eruption are analogous to those which obtain in variola.
Indeed, even the presence of an exudation is not essential to the
production of the umbilicus. An accumulation of sebum, par-

238 scXrlatina (mayr).

ticularly if this remains long fluid, as in the affection described^
under the name of Comedoneuscheiben, and in the Molluscum conta-
giosum, is sufficient to give rise to an appearance very similar to that
of the eruption of smallpox.

As the quantity of pus-globules contained in the fluid of the
variolous pustules increases, we find that the number of epidermic
cells in this fluid undergoes diminution, by what Virchow terms
the process of " cellular substitution" (Zelleusubstitution) . Indeed,
these cells at last almost totally disappear, and the contents of the
smallpox pustules then consist wholly of pus, with a few scattered
blood-discs.

At this time there is observed beneath the roof of certain of the
pustules, and occupying the exact centre of its under surface, a
white discoid substance. This, however, cannot be detached ; and
careful microscopical examination shows that it is made up solely of
epidermic cells, and is not, as might be supposed, an inflammatory
membrane. This white substance, in fact, appears to arise either
from the greater maceration of the epidermis at this point, or from
an accumulation of those cells which at first lined the hair-sac and
formed the root-sheath of the hair, and afterwards have become
pressed mechanically against the roof of the pustule by the fluid now
in great part converted into pus.

Hence it will not seem extraordinary that I should declare the
umbilicus and the so-called pseudo-membrane to be, in reality, met
with both in varicella and in varioloid, as well as in the variola vera.
The fact that these appearances are most frequently observed in the
last-mentioned form of the disease depends only upon the greater
length of time occupied, in cases of variola vera, in the formation of
the pustules. Indeed, I may lay it down as a rule, that if only an
eruption be seated at the mouths of the hair-sacs, the slower its
development the more certainly will an umbilicus be present ; and
that the more quickly vesicles or pustules are formed the more
perfectly spherical will be their shape, especially when they occupy
the inter follicular spaces.

Again, it is stated that the secondary fever (Eiterungsfieber,
Eiterungsstadium, Stadium sujjpurationis) belongs only to the
variola vera.

But, from what has already been said, it will be apparent that pus-
tules are, in the end, developed in each of one of the forms of small-

' V. p. 130.

VARIOLA. 239

pox. 'Now, ill thisj as iu any other disease, the pus so formed
necessarily exerts upon the surrounding structures an irritant action,
which will be severe in proportion to the number of these little
subepidermic abscesses. By the accumulation of these separate
irritations a disturbing influence is^ of course, exerted upon the whole
skin, and also upon the system in general. The red blush (halo)
round each pustule is, in fact, caused by the action of the pus
contained in its interior, and is a visible proof of the irritation
which is set up by that fluid. Now, partly as a result of this
condition of irritation, but, no doubt, still more as a consequence
of the admixture with the blood of particles derived from the
contents of the pustules, there arises a general morbid state,
manifested by acceleration of the pulse and increased heat of skin
— in short, by those symptoms which we group together under
the name of fever. This condition generally sets in after the
tenth day of the disease. According to what I have stated, it
cannot, sensu striclissimo, be said to be caused by the disease itself,
but is rather due to the presence of pus at so many points beneath the
epidermis. Hence, it does not belong to the variola vera alone, but
will present itseK in all cases in which accumulations or foci of pus
(Eiterherde) exist, and in which purulent absorption has taken place.
But, although I dispute the vaHdity of the distinctions hitherto
accepted between the different forms of variola, I have yet endeavoured
to find other characters by which these three varieties might be dis-
tinguished at the bedside ; and in doing this it has been my object
to retain both the names previously used and also the meaning
which has been generally attached to them . Now, a careful observa-
tion of the course of the different modifications of smallpox shows
that, in general, the number of the pustules is directly proportionate
to the duration of the disease. Thus, the variola vera takes the
longest time for its development and involution, a space of four
weeks being the minimum period within which this variety of the
complaint comes to an end. On the other hand, varicella runs
the most rapid and most favorable course, for which fourteen days
at most are required ; and cases of the intermediate variety take, on
an average, three weeks in passing through their stages. These
differences give us the means of practically distinguishing the dif-
ferent forms of smallpox on a basis capable of being expressed in
numbers. Thus, I apply the term varicella to those cases only
which require fourteen days or less for their complctioii ; to those

240 VARIOLA.

which terminate in the third or fourth week I give the name of
varioloid ; and^ lastljj I reserve the title of variola vera for those
which run a course of four weeks or longer.

Variola or smallpox (Pocken, Blattern) presents, in general, the
following characters : — It is contasrious, runs an acute course, is
attended with fever, and leads to the formation of numerous vesicles
and pustules over the whole surface of the skin.

How long the disease may remain dormant in the system before
it breaks out cannot be stated positively of variola, any more than
of any other of the exanthemata. In the majority of cases fourteen
days elapse between the time of infection and the first appearance of
the febrile symptoms which are the precursors of the eruption.
But instances are recorded in which it was clearly shown that the
interval was much less than this ; and there have been other cases in
which the affection broke out at a far later date after the occurrence
of infection.

In works on smallpox we find references to many cases tending to
show that the disease can be communicated by the lower animals as
well as by man, and that even articles of clothing or furniture may
be sources of contagion. But it is very difficult to determine whether
these statements have been thoroughly weighed.

It is well known that during the period of incubation of variola
persons feel perfectly well. This is, indeed, sufficiently proved by
the fact that they do not place themselves under medical care until
the febrile symptoms make their appearance.

Now, since the three varieties of smallpox which I have named
differ greatly in their duration, I am compelled to take one of these
forms as representing the normal course of the disease, from which
the others deviate. Tor this purpose I shall make use of the variola
vera, as being the most severe variety, and the one in which the
eruption is most abundant. After describing the normal course of
this form of smallpox I shall pass on to the special consideration of
its modifications, including those which present still greater intensity
and malignity, as well as those which run a more favorable course.
This will afford me an opportunity of giving an account of both the
varioloid and varicella.

SYMPTOMS. 241

The normal course of 8mcdliiOX [Variola vera regularis, henigna ;
Fehrls variolosa erethica) .

I. T/ie Stadium Prodromorum.

T\\Q febrile symptoms which attend the early stage of smallpox
present nothing peculiar in this any more than in the other acute
exanthemata. The first appearance of the fever is, indeed, generally
sudden, and it displays a great intensity. This is particularly the
case in children, in whom (besides the acceleration of the pulse, the
flush on the face, and the wandering speech) convulsions are fre-
quently observed, so that the disease sometimes simulates the com-
mencement of typhus or meningitis. It must, however, be admitted
that in some cases the febrile symptoms are at first exceedingly slight.
The only distinctive character of smallpox in this stage of the
disease (if, indeed, any character can be said to be distinctive during
this period) is the presence of pains about the joints and over the
sacrum, and also, in some cases, at the scrobiculus cordis. These
pains are often very severe, so that we are not rarely led into error
when the patient asserts that he has received some injury, of which,
however, no sign can be discovered on examination of the part which
is the seat of his suffering.

As a rule, the mucous membranes present no morbid appear-
ances during this stage of smallpox, nor does the patient experience
any subjective sensations referable to these structures. But in
cases in which the mucous surfaces are afterwards severely affected
these are sometimes, from the very first, reddened and swollen ; and
the ])atient, perhaps, complains of a sore throat or a catarrhal
affection.

The violence of the symptoms during this period of variola does
not stand in direct ratio with the severity of the subsequent disease.
For, on the one hand, early febrile and concomitant symptoms of an
intense kind not infrequently precede an eruption which is very
slight ; and, on the other hand, the Variola vera itself is by no means
invariably ushered in by a severe stadium prodromorum.

The average duration of this stage, throughout which the fever is

343 VARIOLA.

constantly on the increase^ may be stated to be, in adults, about
three days. In children it often happens that no striking symptoms
make their appearance in the course of this period, so that the
disease is not rarely overlooked, and the eruption then takes one
altogether by surprise.

In certain cases exanthematic sijm^itoms present themselves during
this period of the disease in the form of the Roseola variolosa or
Brythema variolosum. This rash has already been described among
the symptomatic active hypersemise (vide page ^G).

II. The Stadium 3-tiptionis.

Febrile symptoms, — As soon as the variolous eruption begins to
break out the intense febrile symptoms generally decline, the heat
of the skin, delnium, and drowsiness subside, and convulsions are
no longer observed.

It is only in very severe cases, and generally in the malignant
{2)erniciöse) form of the disease, that a remission of the febrile
symptoms does not occur when the rash makes its appearance.

Concomitant symptoms. — The pains in the joints and along the
spinal column diminish, and may even altogether disappear j nor do
any of the other concomitant symptoms present any gi'eat intensity,
except in very severe cases, in which the mucous surfaces are affected
by the disease.

Hxanihematie symptoms. — The spot at which the rash first makes
its appearance is not in all cases exactly the same ; but in the so-
called variola vera the eruption is always first observed on the face
and on the hairy scalp, only a few scattered papules being seen on
other parts of the body.

The efflorescence develops itself in the following manner: — In
the regions above named, and chiefly at those points which are the
seat of apertures of hair-sacs and sebaceous glands, there arise
minute papules, the size of millet-seeds, slightly reddened, and dis-
cernible by the touch as well as by the sight. The patient at the
same time complains of sensations of pricking or shght itching. In
the course of the first and second days the papules increase in number ;
but, however abundant they may be, they always remain isolated,
and never as yet coalesce. The rash dm-ing this stage presents a
great similarity to that which is observed in the papular form of

SYMPTOMS. 243

measles^ so that it may for a time be impossible to determine whether
the case is one of morbilli or variola. It is only after the termina-
tion of the second day of the eruption, or the fifth day of the disease
(reckoned from the commencement of the stadium prodromonwi) ,
that smallpox presents characters by which it can with certainty be
recognised.

III. The Stadium Floritionis.

During this period i\\Q febrile si/mj^toms diminish in proportion
as the eruption passes from the papular into the vesicular stage^ and
by the fourth, lifth, or sixth day of the disease they have often alto-
gether disappeared. On the seventh day, however, when the contents
of the vesicles begin to become puruleutj there is an exacerbation of
fever, and from this time up to the eleventh day it steadily advances,
so as generally to reach its height (the stadium acmes) between the
ninth and eleventh days.

If on the eleventh day of the disease the coiistitutional symptoms
do not subside, they then assume that form which we are accus-
tomed to see in the (so-called) pysemic affections. The fever, in
fact, acquires an intermittent character, presenting a severe cold
stage, followed by intense heat of skin of greater or less duration.
This febrile state has long been known under the name of secondary
fever (Eiterungsfieber) ; it appears just when pus is formed within the
smallpox vesicles, and has, m consequence, been erroneously looked
upon as the cause of this change in their contents ; whereas it would
certainly be more correct to regard it as the effect of a subsequent
absorption of pus into the blood. Careful observations of the
pulse, continued over a long period, show that variola reaches its
height in 53 per cent, of the cases on the tenth day of the disease,
the pulse being then lOO — 140 in the minute. In twenty-nine out
of a hundred cases the ninth day is the one on which the pulse
attains its greatest rapidity, and in the remaining 18 per cent, the
highest intensity does not occur until the eleventh day.

Concomitant symptoms. — Of these I must especially mention sleep-
lessness, which, indeed, always continues until the disease has reached
its height.

Exanthematic symptoms. — It is during this period, which lasts six
or seven days, that the smallpox eruption presents the stage in its
development most characteristic of the disease. For on the sixth

^4 VARIOLA.

day tlie papules begin to pass into vesicles ; during the seventh and
eighth days these everywhere increase in size ; and on the ninth or
tenth day their hitherto transparent contents become yellow and
purulent^ a transformation, which, however, does not occur before
the eleventh or tweKth day in the vesicles which are found on the
limbs, where the eruption ajjpears later than on other parts of the
surface.

When the pustules are very numerous they of course lie close to
one another, and this involves a swelling of the intermediate tracts
of skin which are not themselves occupied by the eruption. More-
over, from the tenth day of the disease onwards each pustule becomes
surrounded by a red rmg (the so-called halo). These changes
produce an extreme disfigurement, especially of the face ; the eyelids
become closed by cedematous swelling ; the nostrils are plugged up ;
the hps protrude outwards. Of the otlier parts of the body, where
the pustules are developed a day or two later, those which become
most swollen at this period of variola are the hands and the feet
(and particularly the soles) ; and, Avhen the epidermis of these
regions is tliick, severe pain may thus be produced.

Although the smaUpox eruption is generally pretty uniformly dis-
tributed, it yet has a predilection for certain parts of the skin.
These are, first, the face and the scalp (where the pain is also gene-
rally most severe), next the upper extremities and the trunk, then
the lower Hmbs and the genitals, and, lastly, the abdomen. This
region is often the seat of very few pustules, even when they are
elsewhere tolerably numerous.

The previous occupation of the patient exerts a marked influence
upon the number of pustules present at certain spots. Thus, in
maid-servants, and in men and women who practise certain handi-
crafts (Handarbeiterund Handarbeiterinnen), the hands are apt to be
kept in a state of irritation by the action of soap or alkaline lye, or
some similar substance ; and when this is the case, the hands present a
more abundant crop of pustules than usual. So, also, any part of the
body round which a belt or garter, stays, or even the coat or gown, or
any other article of clothing, has been tightly fastened, or which has
been for some time subject to considerable pressure from a truss or
bandage, is generally covered with the smallpox eruption. Again,
the buttocks of persons of sedentary habits, any parts of the skin
which have been exposed to irritation from sinapisms or blisters or
other local applications, and, lastly, any spots which were the seat

SYMPTOMS. 245

of eczema or any other exudative affection before tlie appearance of
the variola — all such parts present numerous pustules, and may even
be covered with confluent eruption^ although this is quite scanty in
other regions.

On the other hand, in cases of ichthyosis or prurigo the opposite
of this is observed. In persons affected with either of these dis-
eases the smallpox efflorescence appears only on the flexures of the
joints and on the genitals, and face ; in other words, on those parts
of the skin which were previously healthy.

IV. The Stadium Exsiccationis seu Becmstationis.

Febrile and concomitant spnptoms, — When the disease runs its
normal course the febrile symptoms come to an end on about the
thirteenth day. The pulse is now generally about 80 and 90 ; sleep,
which has been absent from the beginning of the malady, is again
enjoyed ; the appetite becomes sharp ; the patient feels comfortable,
and complains of nothing but the eruption on his skin.

Exanthematic symptoms. — Some of the pustules seated on the face
first lose their fluid contents by desiccation and absorption, and
become converted into a brown solid mass — in other words, into a
crust. On each succeeding day the same change extends to pustules
which were later developed ; and, sometimes, it may even affect a
large number of them simultaneously, so as to produce a great altera-
tion in the appearance of the patient, l^or, as the eruption dries
up, the swelling of the skin gradually subsides, and the redness
round the individual pustules disappears. The tension and pain
produced by the presence of so severe and extensive an efflores-
cence daily undergo diminution. The eyelids, so long closed, are
again opened, and the globe of the eye is found to be uninjured.
The plugged- up nostrils are rendered pervious by the removal of
the accumulated crusts ; the Kps can again be brought into contact ;
and, except when* the mucous membrane of the mouth was some-
what severely affected by the disease, there is no longer an excessive
secretion of saliva or mucus.

The order in which the pustules undergo involution and decrus-
tation is the same as that in \ihich they are developed. Starting
from the face, these changes gradually spread over the whole body.
It is, however, to be noted that desiccation occurs on the hands and

246 VAUIOLA.

feet, and particularly on the palms and soles, earlier than on other
parts of the limbs. ]\Ioreover, the crusts which form on the hands
and feet present the peculiarity that they are solid lentil-shaped
bodies, as it were encapsuled within the epidermis. Thus they differ
essentially in their form, as well as in their browiiish-black colour,
from the crusts which are to be seen on the other regions of the
body.

By the end of the fourth week these crusts everywhere become
detached from the surface of the cuticle, which, in the mean time,
undergoes regeneration. They may leave behind them either mere
deposits of pigment, or scars, which will be more or less marked,
according as the pustules were originally seated in the deeper struc-
tures of the skin or occupied a more superficial position.

Anomalies in the course of Variola,

In the severity of the cutaneous affection which accompanies it,
smallpox presents greater varieties than any other of the exanthe-
mata. This fact has long been observed, and was doubtless the origin
of those subdivisions of the disease which have in every age been
recognised. Thus, variola was at one time distinguished into a mild
and a severe form ; and, at the present day, thi'ee varieties of this
disease are generally admitted, namely. Variola vera, the Varioloid,
and Varicella. It would, in reality, be difficult to say which of
these three forms constitutes the normal course of the disease. I
shall, however, follow the usual practice (which also accords with
that adopted in the other exanthemata) of regarding as typical the
benignant variety which mostly terminates in recovery ; so that I
shall reckon as modifications of this type both the more severe and
the milder forms of variola.

I certainly might, in this matter, follow the example of Sydenham,
Boerhaave, Sauvages, and others, who distinguished merely two
forms of this disease, a benign and a malignant — the Variola discrete
and the V. confiuentes. There are, however, iinportant objections
to such a division, and among them the fact that some cases of dis-
crete smallpox run a mahgnant, some cases of confluent smallpox a
benign, course. I therefore prefer to make use of the terminology
ordinarily employed, and shall retain the threevarieties of which I
have already given the names.

ANOMALIES. 247

The most numerous irregularities are undoubtedly met with in
that form of smallpox which was formerly termed the Variola con-
fluens, and has more recently received the name of Variola vera.

These anomalies in the course of the disease make their appear-
ance in its later stages rather than in the stadium prodromorum
which has for the most part a uniform duration of three days, and
presents in each variety of smallpox the same intensity. In the
stadium eruptionis, however, we find that the more numerous tlie
papules the more slowly are they developed ; and the conversion of
the papules into vesicles, and of these again into pustules, is like-
wise retarded, so that in cases of Variola vera we have to allow two
days for this stage, whereas in the Varioloid it is only of twelve or,
at most, twenty-four hours' duration, and in Varicella it often does
not last more than a few hours, so that it may easily be altogether
overlooked.

The stadium floritionis, again, occupies a week in cases of the
Variola vera, while in those which are of less intensity it does not
take more than half that time.

In regard to the distribution of the pustules, and the order of suc-
cession in which they are developed, it may be observed that in the
Variola vera s. confluens the eruption appears first on the face and
afterwards spreads over the surface of the body in the anatomical
order, but that in the other forms it as often breaks out first on the
skin of the trunk as on that of the face.

Lastly, the length of the period of decrustation is also propor-
tionate to that of the s. erujjtionis and the s. floritionis. The more
numerous the pustules the more time will be requh-ed for their
complete conversion into crusts.

It is obvious, then, that in severe cases Variola extends over a
longer period than the four weeks which I gave as the normal limit
of its duration.

The concomitant symptoms vary with the number of pustules.
The swelling of the skin, the annoying sensation of tension, some-
times even amounting to pain, the closure of the eyelids, the per-
manently open state of the mouth, the suffering with which every
movement is accompanied, the uneasiness caused by the recumbent
posture, and, lastly, the pains experienced in the hands and feet,
particularly in the latter, Avhen covered with a tliick horny cuticle —
all these symptoms become aggravated as the quantity of pustules
increases, and as their development advances.

248 VARIOLA.

On the otlier hand^ those cases of smallpox in which the eruption
presents the mildest possible form take a very different course. Under
these circumstances febrile distui'bance is often altogether absent
( Variola apyretica), and the patient is also quite free from pain; indeed,
if the scanty efflorescence on the surface of the skin did not indicate, by
its characteristic form, the nature of the disease, his sensations would
not lead him to suspect that he was suffering from smallpox. Cases
even occur in which the consecutive decrustation is the first thing which
enlightens either the patient or the physician as to the nature of
the complaint, and in which it would, indeed, be impossible to make
a diagnosis if smallpox were not epidemic, or if, at any rate, other
patients in the same district did not, at the time, present unmis-
takable symptoms of the disease.

In several cases, even in the confluent form of smallpox, I have
observed a modification which is very welcome to both the patient
and the physician. This consists in the sudden subsidence of the
complaint on the tenth day, the eruption having previously passed
through the usual changes, and being then in a state of full de-
velopment. Decrustation, in fact, at once commences, and goes on
so rapidly that in the course of a few days all the pustules are
converted into brown crusts. This renders the course of the
disease extremely favorable in every respect, and also much
shorter than usual, not lasting more than three weeks. Hence,
such cases, although at first set down as Variola vera, are brought
into the group of the Varioloid affections by the rapidity with
which decrustation occurs.

Irref/idar Forms of the Bask.

Writers have described numerous varieties of the smallpox erup-
tion, to which they have given appropriate names. Thus, we meet
with the followmg terms: — Variola j^ajmlosa [Nirlns, Alibert),
conica, acuminata, glohosa, gloiulosa, verrucosa, tuberculosa, cornea,
silifpiosa, fimhriata, miliaris, crystallina, lymphatica, vesiculosa,
jpempltigosa, pustularis, rosea, morlillosa, carhunculosa, &c. These
varieties, however, are all of such trifling importance that it is need-
less to give a further description of them, especially as those who
may desire to distinguish them will find that the epithet attached to
each sufficiently indicates its appearance. Indeed, what I would

IRREGULAR FORMS. 249

principally insist upon is that the cause of these differences in
the size of the pustules, and in the form of the eruption, lies
in the fact that the pustules, which arc always at first small,
sometimes retain the same form throughout their whole existence ;
whereas in other cases they blend together by twos or threes, thus
acquiring a much greater size ; and in yet other instances a large
number of them coalesce, so that the eruption presents the modi-
fication known as the Variola corymlosa, or even that a sort of
bleb is formed (sie blasenähnliche Eflflorescenzen bilden).

I must also not omit to mention that smallpox pustules group
themselves in those lines which (as we learn from the admirable
investigations of Professor Voigt^) are indicated by the arrangement
of the hairs on the different parts of the surface (Haarwirbel), which
arrangement itself ultimately depends on the distribution of the
cutaneous nerves. As an illustration of this, I may just refer to the
fact that on the trunk the pustules are disposed in lines running in
the düection of the ribs, and that about the nipple they are placed
in semicircles, arranged more or less concentrically round it.

Par more important than those of which I have been speaking
are the varieties of smallpox in which there is an altered state of the
contents, or rather (strictly speaking) of the hase of the pustules.
Sometimes, for instance, either quite early in the disease or during
its later stages, the eruption displays a bluish-red or black colour.
This is always a proof that extravasated blood is present, in addition
to the usual serous or purulent fluid. Now, if this appearance is
presented by only a few of the vesicles or pustules, it merely renders
the part tender or painful, and in this form it is not peculiar to
variola, being observed, for example, in Her^ies zoster also. On the
other hand, it is always a bad sign to find that the base of all or
even many of the vesicles is infiltrated with blood, or that they are
filled with a bloody serum. This variety of the disease has been
termed the Variola Immorrhacjica sen nigra, the latter of these
epithets being given to it chiefly because, in the stadium decrusta-
tionis, all the crusts assume a black colour.

This, too, is the proper place to mention another modification of
variola, that in which the only manifestation of the disease is the

^ ' Abbaudlung liber die Richtung der Haare am menscbliclien Körper,' von
Dr. Clir. Aug.Voigt, Prof. d. Anat.,Wienj k. k. Staatsdruckerei, 1857. 'Beiträge
zur Dermatoneurologie, uebst der Beschreibung eines Systems neuer Linien an
der Überfläche des menschlichen Körpers,' von demselben, ibidem, 1864.

250 VARIOLA.

formation of lisemorrhagic spots. Such cases do not at all resemble
those of ordinary smallpox, and, in fact, it is only during an epidemic
that we can positively determine them to be due to the variolous
poison. Their course is as follows. After febrile symptoms, which
set in suddenly and with great severity, and are attended with
delirium, or sopor, or with convulsive movements, cramps, &c., there
appear on the skin a large number of hsemorrhagic (blutig sufFun-
dirter) spots, of the size of millet-seeds or lentils. These spots
rapidly increase in size, become more and more numerous, and,
within forty-eight hours, generally cover the whole surface of the
body. Such cases always terminate fatally, and, for the most part,
within from three to five days after the commencement of the disease.
On post-mortem examination all the mucous membranes and the
fibrous and serous tissues are found, like the skin, to be infiltrated
with blood. Moreover, the parenchymatous organs, such as tlie
lungs, heart, liver, and spleen, are in a similar condition; indeed, the
spleen is often so soft that it looks like nothing but a mass of blood
enclosed in a fibrous capsule.

Although this form of smallpox is now of very rare occurrence, it
appears to have been much more common before vaccination was
introduced, and especially in certain epidemics; and it was then
known under many diff'erent names {BhifJIeckenkrankheit, Furpimi
febrilis, ScJmarzer Tod).

J^arieties of Smallpox due to the presence of other ciitaneovs
affections, or of diseases of internal organs.

A. Coexisting diseases of the Skin.

{a) Bnjna variolosa. — In certain cases of variola each crust
becomes surrounded, in the course of the stadium decrustationis,
with a small vesicular ring (Blasenwall), containing a puriform fluid.
This appearance is observed especially on the surface of tlie thorax ;
it arises on the fifteenth day of the disease, or a little later, and is
attended with a renewal of the febrile disturbance. The central
crusts, with the vesicles round them, present a great likeness to a
Riijna syphilitica, and the more so because after a few days, when
the fluid contained in the first-formed ring has dried up, this
becomes surrounded by a second ; this again, still later, by a third ;
and [so on. In fact, the crusts produced in this way sometimes

COMPLICATIONS, 251

cover a surface of au inch in extent. It appears to me that this
remarkable modification of the smallpox eruption may be appro^
priately termed a Rupia variolosa.

[b) hni^etigo variolosa. — In other instances a consecutive sup-
puration appears^ not round the crusts formed from variolous pustules,
but in the intervening spaces which were free from the efflorescence.
Thus^ there appears a second pustular eruption, which might almost be
regarded as a second smallpox eruption, were it not that the pustules
have a different form, and take a different course. In fact, they
resemble rather those of the common pustular affections, and
therefore this affection may be called the Impetigo variolosa.

Both this and the preceding affection are to be regarded as repre-
senting metastatic deposits, as also are those which I have next to
describe.

(c) Ftinmc2ilosis, abscesses, pseuclo-erysipelas. — In some cases
such deposits appear as furunculi, or in the shape of abscesses or
small subcutaneous collections of pus, or are even still more deeply
seated, taking the form of pseudo-erysipelas or inflammation of the
areolar tissue. This last affection has the more claim to a special
description because it is among the most dangerous of the com-
plications of variola. It generally sets in about the end of the third
week ; the patient first complains of pain in particular spots, which
are extremely tender, and sensitive to the slightest pressure. Neither
the eye nor the touch of the physician would as yet be able to
discover any morbid deposit at these points ; but, a few days later,
they are found to be swollen and oedematous, and soon afterwards
fluctuation, which is sometimes indistinct, can be detected by the
finger. If an incision is made into one of these painful spots there
escapes, even at this time, a large quantity of pus, of which the
amount seems quite out of proportion to the size of the swelling.
These .forms of cellular inflammation are met \\ith especially on the
upper arm and on the other limbs ; they are less common on the
trunk. The swelling may be of the size of a pigeon's egg, or may
reach a diameter of \%" or even more. Indeed, in some cases
the skin of a whole hmb, or of the whole back or chest, becomes
undermined by these accumulations of pus, so as to form the roof of
a single enormous abscess.

iß) Gangrene. — This complication is of still worse augury
than those of which I have been speaking. Gangrene may either
be consecutive to pustules, furuncles, cellular inflammations, or

252 VARIOLA.

abscesses, or it may arise directly by the formation of a bleb which
is filled with bloody serum, and has a base infiltrated with blood.
It then rapidly spreads to the adjacent parts. The blackish-
brown eschar thus formed becomes detached after several days,
exposing a loss of substance of greater or less extent. Sometimes,
indeed^ all the soft parts are destroyed over a larger or smaller area,
so that the bones are laid bare. It appears almost incredible, but it
is a fact, that these patients sometimes live on for several weeks, with
their bones, so to speak, dissected out ; ultimately, however, they
almost all sink. Gangrene is a complication which appears espe-
cially in certain epidemics of variola.

{e) Dlp/d/ieritis cutanea. — When any part of the skin has been
deprived of its epidermis (as, for instance, by the a])plication of a
blister), either just before or during the early stage of a severe
attack of smallpox, it sometimes happens that the denuded spot
becomes covered with a diphtheritic membrane, which is at first
white, but afterwards acquires a brown appearance. This peUicle is
a line in thickness, tough and leathery, and so firmly adherent to
the subjacent cutis as to be absolutely inseparable, even by force.
Its formation is attended with febrile symptoms, and is certainly not
to be regarded as a favorable sign. If, however, the disease should
take a benign course, the diphtheritic membrane gets surrounded by
a suppurating border, and gradually becomes undermined by pus,
so that it separates in the form of a continuous slough. The loss of
substance wliich remains is next replaced by healthy granulations,
and the wound heals, leaving behind it a scar.

B. Disease of the Mucous Membranes.

Those mucous surfaces which can be seen during life, and par-
ticularly those of the mouth, throat, and nasal cavities, are very
frequently attacked by variola. The membrane then becomes red-
dened and swoUen, there is an excessive secretion of mucus and
saliva, and an efflorescence makes its appearance, consisting of more
or less numerous elevations, which lie side by side, and are at first
of the size of millet-seeds and of a whitish colour ; at a later period
the summit of each of these elevations presents a small red point,
beneath which the excoriated mucous membrane is to be seen, and
which owes its origin to a maceration of the epithelium. For the
epithelium of these parts being constantly bathed with fluid, and

COMPLICATIONS. 253

being far more delicate than the cuticle of the skin^ the smallpox
efflorescence does not on the mucous surfaces give rise to firm
vesicles, filled with fluid, such as are seen upon the integument ;
on the contrary, the contents of the vesicles at once escape, in con-
sequence of the maceration of the epithelium and the shedding of
its most external lamina ; and in this way the appearance just de-
scribed is produced.

Moreover, the surface of the mouth and the salivary glands secrete
a quantity of fluid proportionate to the number of the vesicles. The
secretion thus formed may sometimes be so profuse as to constitute
a serious degree of salivation. This adds another severe trouble to
the many which afflict the patient, who now lies day and night
with open mouth, from which large quantities of saliva are con-
tinually flowing.

The mucous membrane principally affected is sometimes that of
the lips, sometimes that of the cheeks, the tongue, the soft and
hard palate, the throat (particularly its posterior wall), or the
larynx. Corresponding to these difPerences, there is in some cases
considerable swelling of the lips, while in others the movements of
the tongue are much impaired. This organ often appears thick and
swollen, and protrudes between the lips, and its tip, which is
thus exposed to the air, becomes covered with a dry brown coat
[Glossitis variolosa). In some instances, again, there is difficulty of
swallowing, or hoarseness ; or, if the mucous membrane of the nose
is likewise affected, the nostrils become plugged by the crusts which
are formed, and this interferes with the respiration.

Except in children, these symptoms are not attended with the
dangerous consequences which we should, at first sight, be inclined
to attribute to them. Indeed, they subside altogether long before
the eruption on the skin undergoes decrustation ; they give rise to
no further troubles, and lead to no sequelse. Hence, by the time
that the other symptoms of the disease begin to decline the afiTec-
tions of the mucous membranes also cease to annoy the patient, and
present no obstacle to his taking nourishment.

In children, however, the case is different. In newly born infants
a severe affection of the surface of the mouth and throat is one of
the most dangerous complications of variola, because the child is
thereby rendered unable to suck, and is consequently condemned to
starvation.

It is well known that the smallpox efflorescence sometimes ex-

254 VARIOLA.

tends along the mucous membranes which line the internal organs,
passing, for example, into the air-passages as far as the ramifications
of the bronchial tubes, or into the oesophagus, or, again, from the
anus upwards as far as the commencement of the rectum. In
examining the bodies of smallpox patients after death we often find,
on other parts of the mucous membranes, small erosions and ulcers
resembling those seen in persons who suffered from diarrhoea, but
never appearances which are identical with those met with on the
mucous surfaces previously named.

To what extent the auditory passage takes part in the variolous
process cannot be positively stated. Even when the disease is at its
height, and when the pinna and the external auditory meatus are con-
siderably swollen, the patients invariably hear pretty Avell, and answer
the questions put to them.

c. Biseascs of the Ej/e.

Although the structure of the conjunctiva is, of course, analogous
to that of the mucous membranes, it is only in very exceptional
cases that we find this surface affected by smallpox. Indeed, the
ocular conjunctiva is never extensively involved; and we at most
find a very few pustules on the margins of the lids, close to the roots
of the eyelashes and the apertures of the Meibomian glands. The
membrane covering the eye may now and then display a pustule of
the size of a pin's head, very superficial and filled with a yellow
iluid. This, however, quickly bursts, bemg macerated by the
conjunctival moisture, and is not followed either by an excoriation
of any size or by any disease of the subjacent structures.

When we compare the results of observation at the present day,
with the descriptions given in the older works, it appears quite in-
explicable that so much should have been Avriten in these books con-
cerning variolous infiammations of the eye. Tor I can positively
assert and prove from the records of more than 5000 cases of small-
pox that even the superficial pustular aftection which I have been
describmg has occurred only in 1 per cent, of these cases, and has
never caused any, even transient, injury to, or disfigurement of, the
eye itself. And I may at once say that this result was not due
to any prophylactic treatment applied to the eye itself, by which the
formation of pustules on the ocular conjunctiva was checked.
Indeed, as I shall hereafter show, I have found no necessity for

SEQUELiE. 255

any kind of treatment, whether prophylactic or curative, and
therefore I have given no medicine to the smallpox patients under
my care.

I do not, however, mean to assert that variola can never, under
any circumstances, imperil the organ of vision. But when this does
occur it is the result, not of an ulcerative action extending from the
surface to the deeper parts, but of the formation of metastatic de-
posits within the eye. This affection I shall hereafter describe
among the sequelae of smallpox.

D. Diseases of Internal Organs.

Various complaints come under this head ; among them are dis-
eases of the lungs, such as lobar and lobular pneumonia, and intes-
tinal disorders, including diarrhcea and dysentery. These alfections,
however, are attended by no symptoms other than those which are
well known as belonging to their ordinary forms, and therefore no
further description of them is necessary.

Segnelee of Smallpox.

I apply this term to those diseases which are called into existence
directly by the variolous process, and remain as a continuation of it
when the exanthem itself has passed off.

Among the cutaneous affections which come under this head are,
first, sehonhoßa and acne.

We find from observation that even while the crusts formed by
the drying-up of the smallpox pustules are still adherent to the
skin accumulations of sebum frequently occur beneath them, occu-
pying, in fact, the mouths of the hair -sacs, which have again become
patent. In some cases these masses of sebaceous secretion, being
attached to the under surfaces of the crusts, interfere with their
separation. In other instances, again, they remain within the ducts,
and appear in the form of comedones after the crusts have fallen ofl*.
Or, lastly, they may even become raised above the surface of the
skin, covering it with a grayish-yellow pellicle if the variola was
confluent, but appearing as isolated warty elevations after the dis-
tinct form of the disease. The first of these varieties is a Seiorrhcea

256 VARIOLA.

sicca, seu sqiia'niosa ; the other constitutes the Variola verrucosa
(warty pocks).

In other cases numerous small abscesses and tubercles make their
appearance after the separation of the crusts, forming an Acne pustu-
losa. They are seen chiefly on the nose and face, but differ in no
respects from other pustular affections.

Figment spots and cicatrices after Variola. — The deposition of
pigment at those spots which were the seat of smallpox pustules is
observed after every form of the disease, but especially after the
Variola vera and the V. modificata. It occurs in the form of maculas,
which are of the size of lentils, and are either distinct or (more
rarely) confluent at their borders. Their colour is more or less
deep, and does not fade or disajjpear beneath the pressure of the
finger. In some cases the centre of these spots displays a depression
which is of a lighter tint, and Avhich, even at this time, and still
more plainly after the disappearance of the pigment, is seen to be a
small cicatrix. These scars are observed particularly at those points
which were occupied by the more deeply seated variolous pustules,
and especially where these were confluent. But in no case do we
find cicatrices left by every one of the pustules which were present.
Even in the most severe forms of confluent Variola vera the disease
leaves marks of its presence only at certain spots. Unfortunately,
the face is most frequently the part at which these scars remain
visible.

The cicatrices of smallpox differ in no respect from those which
result from an Acne pustulosa ; and we are, therefore, not warranted
in speaking of them as characteristic of the former disease. It is
only the uniform distribution of these scars and the fact that they
are found principally on the face which can enable us to determine
that the individual has previously been affected by variola.

I must not omit to mention that cicatrices may be and are formed
in each of the varieties of smallpox, even in the mildest form of that
disease. All that is necessary is that the pustules should penetrate
into the substance of the corium. It is quite incorrect to suppose
that these scars are produced by the patient's scratching himself
while the eruption is out.

The development of the smallpox efiSorescence on parts of the skin
occupied by hairs, or beneath the nails, leads subsequently to a
temporary or permanent loss of these structures. .Thus, when small-
pox pustules have been developed in large numbers on the scalp, so

SEQUELS. 257

as to destroy a large number of the liair-sacs, the hairs will^ of
course^ be ever afterwards deficient at these spots. But if, on the
other hand, the eruption^ tliough occupying the head, has been quite
superficial, so as to leave behind it very sliglit cicatrices, or even
none at all, then, although the hair may at first fall off, it will yet
grow again after the termination of smallpox as after any other severe
disease. This is true also of the nails, beneath which (that is, on
their bed) smallpox pustules are frequently developed. AVhen this
occurs a spot of pigment afterwards makes its appearance on the
surface of the nail, but is gradually thrown ofl' by its subsequent
growtli, and is not followed by any further injury to this structure.
But if the pustules are deeply seated, involving the matrix luujiihy
the disease then, of course, leads to a permanent loss of the nail.

When a person previously affected with any other acute or chronic
skin-disease is attacked by smallpox, it generally happens that during
the presence of the variola the pre-existing cutaneous complaint
disappears. The exanthem is, in fact, developed with peculiar in-
tensity on the parts already diseased, which become covered by the
smallpox efflorescence to such a degree, that the previous eruption
loses its original appearance. Thus, in patients suffering from eczema
or psoriasis, or syphilitic eruptions, the parts so affected present a
larger number of variolous pustules than other parts of the cuta-
neous surface. Other chronic skin affections make no advance so
long as the smallpox is present. In patients affected with scabies,
the acari themselves perish, and their eggs alone survive. But
when the smallpox has run through its course, the other disease,
whatever it may be, returns ; the psoriasis or the eczema reap-
pears ; the prurigo sets in afresh with renewed itching, which had
been absent during the presence of the smallpox. My own obser-
vations lead me to believe that pre-existing chronic skin affections
are very rarely permanently cured by an attack of this disease.
Most frequently all that it (like many other severe maladies) effects
is to check for a time the progress of the chronic cutaneous com-
plaint, which, however, breaks out with renew^ed violence after the
termination of the exanthem.

As is well known, suppuration occurring in the skin always leads
to swelling of the adjacent lymphatic glands. There is, therefore,
nothing extraordinary in the fact that, in smallpox, the glands which
receive the cutaneous absorbents should become more or less gene-
rally enlarged. AVhen the disease takes its normal course, how-

258 VARIOLA.

ever, the swelling of these structures subsides as the variola itself
declines. But in some cases they still remain enlarged, and this
condition may persist for a long time, or even tlu'oughout the whole
life of the individual. In other instances, again, pus forms within
them, and they then go through the ordinary course of suppurating
glands.

Moreover, the glands which are situated in the interior of the
body become affected in the same way as the superficial glands and
the salivary organs, the symptoms thus produced being those which
generally result from morbid conditions of these structures.

Unlike morbilli, variola is rarely followed by tuiercidosis. How-
ever, in patients who presented well-marked signs of tuberculous
disease before the outbreak of the smallpox, the tuberculous affection
is aggravated by this exanthem.

Among the most unfavorable symptoms which follow smallpox,
are those due to the formation of metastatic deposits in different
parts of the body. The most frequent seat of such deposits, in variola,
is the subcutaneous tissue, which generally becomes affected at
various points, particularly on the extremities. Abscesses form, and,
after the discharge of the pus which they contained, large cavities
are left, showing that there has been an extensive loss of substance.
In persons healthy in other respects, and of sound constitution,
these cavities are for the most part quickly filled up, and lead to no
further ill effects, except the cicatrices by which they are followed.
But, in cachectic individuals, and particularly during certain epi-
demics, the granulations form very slowly ; and in some cases these
abscesses begin to spread, burrowing extensively among the adjacent
structures, penetrating down to the bones, attacking the periosteum,
and even causing necrosis.

These metastatic affections of the subcutaneous tissue and the
skin may also give rise to gangrene, occurring (as has already been
mentioned under the head of the Complications of Smallpox,) in
either the moist or the dry form. The losses of substance thus pro-
duced are sometimes very extensive, and usually put an end to the
patient's existence so rapidly that they lead to no further sequelse.

Diagnosis of Smallpox.

The symptoms of smallpox are so characteristic, that it requires
uo very practised eye to recognise the ordinary form of this malady.

DIAGNOSIS. 259

Cases of severe variola^ when the eruption is at its height, are parti-
cularly easy of diagnosis. But it is otherwise when it is first
breaking out, and in the milder forms of the disease, in which the
efflorescence is present only in small quantity.

The following are the cutaneous affections with which is it pos-
sible to confound variola :

1. MorhiUi in that variety which is attended with the develop-
ment not of maculic, but of papules. This mistake is frequently
made, and is very excusable, since in each case the cutaneous erup-
tion has much the same appearance, and is first seen on the fourth
day of the disease. About this period, in fact, there are observed
papular elevations of a reddish colour scattered over the whole, or,
at any rate, over a large part of the cutaneous surface. It may,
indeed, be said that the rash of measles has a much darker colour,
and that the papules in that complaint are bigger, being at least as
large as lentils, while those of smallpox are of a smaller size, and of
a paler hue. Moreover, in variola the eruption successively aflects
different parts of the skin in their anatomical order, and, therefore,
the largest papules are situated on the face and trunk, while those
which occupy the limbs are of more recent formation : whereas,
in morbillij the papules on all parts of the body present nearly the
same degree of development. But, in reality, these characters are
not sufiicient to enable the nature of the disease to be determined
in this stage, and nothmg but the further observation of the case
can effectually save us from the chance of giving an erroneous dia-
gnosis. Tor, after twenty-four hours have passed, the difficulty will
have disappeared. If the disease be smallpox, the eruption will
have undergone further development ; if morbilli, it will have sub-
sided into a macular form. Another distinction, which it is neces-
sary to notice, is that the affection of the mucous membranes is
more intense in measles than in smallpox. Its presence is not,
however, so exclusively confined to the former of these complaints
that we can infer, with certainty, from the prominence of catarrhal
symptoms, that the case is one of morbiUi.

2. There is a still closer resemblance between certain syphihtic
pustular eruptions and the milder varieties of smallpox (varioloid
and varicella), at the time when the pustules are fully developed, or
in other words, durhig the stage of suppuration.

So far as their external form is concerned, indeed, it is quite
impossible to distinguish these affections. The similarity between

260 VARIOLA.

these diseases was insisted on both by Alibert and by Cazenave.
The former gave to such syphilitic affections the name of ' SypUlu
pustulans variolo'ides,' on account of their being so like the varioloid ;
and the latter termed them the ' Si/philide en forme de varicelle,' in
consequence of their resemblance to varicella. In fact, as I have
already mentioned, when giving an historical account of variola,
it was this which gave rise to the names smallpox, petite veröle,
in contradistinction to the great pox or grand e veröle. It must not
be supposed that the presence of fever in variola, and its absence
in the syphilides, is sufficient to distinguish these affections from
one another. There are cases enough of varicella which go through
their whole course without any acceleration of the pulse, or in-
creased heat of skin ; and, on the other hand, the pustular syphi-
lides are frequently attended with febrile symptoms, or complicated
with some febrile disease. The only certain indication of the presence
of smallpox in these cases is the fact that the efflorescence, when
carefully examined, is found to present almost the same degree of
develo])ment over the whole surface of the body; whereas the
pustules of syphilis never all exhibit the same form. These last, in
fact, make their appearance not simultaneously, but in an uninter-
rupted succession, and, therefore, they may be seen at the same
moment in every stage of development and involution.

It is true that, in applying this distinction, we meet with a difficulty
in the fact that varicella is often developed by successive erup-
tions, at intervals, generally speaking, of some days. Wlien this
occurs, the efflorescence certainly presents at the same time various
stages of development and of retrogression. In such cases, the
only way to arrive at a correct conclusion is to examine carefully the
whole surface, ]iot only of the skin but also of the mucous mem-
branes, so far as they can be seen, taking into consideration, like-
wise, the condition of the other organs ; unless, indeed, one has the
opportunity of forming a right diagnosis by watching the further
course of the affection. If we can do this, there is, of course, no fur-
ther difficulty. Tor, smallpox being an acute disease, the variolous
eruption wiU, within a few days, have undergone decided changes,
either in the direction of furtlier development, or in that of involu-
tion; whereas, in syphihtic complaints, such alterations in the
appearance of the skin affection will present themselves only after
the lapse of several days or even weeks. Thus,, one may very well
be in doubt for a few days, but this uncertainty can never be of

PROGNOSIS. 261

long duration^ because variola always runs an acute course, while tlie
sypMides are invariably clironic.

3. Another cutaneous disease, which bears a certain distant
resemblance to smallpox, is the acne pustulosa. This affection,
however, is generally seated only on the face, chest, and back, and
leaves the limbs untouched; moreover, it is not Jiomogeneous, but
consists at the same time of papules of various sizes, and of pus-
tules ; lastly, every one of these presents in its centre a comedo.
These differential characters surely make it appear impossible that
this disease should be confounded with variola after the skin has
been carefully examined.

4. After the termination of the variola, there remain, as is well
known, spots of pigment on the surface of the skin, which, in some
cases, bear a distant resemblance to the copper-coloured maculae of
syphihs. But here any mistake will be at once cleared up by the
total absence of infiltration of the skin, or desquamation of the
cuticle, at the points which are the seat of pigment-deposit.

5. Glanders is another disease which gives rise to the formation
of subepidermic abscesses, which sometimes look like variolous pus-
tules, becoming confluent. In this complaint, however, there are
always, in addition, deep-seated abscesses, with infiltration of the
areolar tissue, hsemorrhagic infiltration of the muscles, or gangrene
of some part of the body. Hence glanders can hardly be mistakeii
for smallpox unless one pays attention to the pustules alone,
omitting to take into account the other symptoms. But further
observation will, even then, remove any doubt that may exist ; for
in this disease the eruption does not pass through its stages so
rapidly as in variola.

Prog7iosis of Smallpox.

In giving a prognosis in a case of variola, it is necessary to
consider which form of the disease is present, what are the indi-
vidual peculiarities of the patient, whether or no he has been vacci-
nated, and lastly, what is the character of the prevailing epidemic.

In general, it may be said that the more numerous the pustules
the more dangerous is smallpox, and that its course is favorable in
proportion as their number is small. Thus varicella always termi-
nates in recovery ; and it is only in cases of varioloid and variola
vera that a fatal issue can be feared. But even in these forms of

262 VARIOLA.

the complaint the prognosis is, at the present day, far more hopeful
than formerly. For, in this country at least, most people have been
vaccinated; and statistical inquiries have shown, that while among
those who are unvaccinated the mortality amounts to 30' i per cent.,
it is not more than 5*2 per cent, in persons protected by vaccination.^
Moreover, this very circumstance gives to all the epidemics of small-
pox a much milder character than they at one time displayed.
Indeed, if no complications arise, even severe cases of this disease
do not often terminate unfavorably.

If, soon after' the formation of the pustules, their contents are
stained with blood, or if their base is the seat of hajmorrhagic infil-
tration, an unfavorable prognosis must be given, at any rate when
such appearances are presented by a large part of the efflorescence ;
and the existence of numerous ecchymoses, besides the ordinary
smallpox eruption, justifies a similar opinion as to the probable issue
of the case. On the other hand, the presence of well-developed, fully-
distended, regular pustules, should lead to an opposite conclusion.

The individual peculiarities (Individualität) of the patient, again,
are very important in relation to ju'ognosis. The younger he is, the
more dangerous is variola ; nor has any circumstance more influence
on the result of this disease, than the age of the subject whom it
attacks.

Children at the breast even now for the most part die, when
affected with smallpox. This arises chiefly from the fact, that the
numerous pustules developed on the mucous membrane of the
mouth and throat prevent the infant's obtaining nourishment by
sucking, so that it commonly perishes from inanition. However,
even unvaccinated children, if healthy in other respects, generally
pass favorably through the milder forms of the complaint.

Among adults, a fatal termination of variola is observed far more
often iji women than in men ; those who are pregnant, or who have
been recently confined, being especially imperilled by this disease.

' The numbers given in the original are 33 per cent., 12 per cent, respec-
tively. I have, however, the authority of Prof. Hebra for saying that this is
a misprint. There is a reference in the text to the "Papers relating to the
liistory and practice of Vaccination," in which are contained reports from Prof.
Hebra, and also from the 'k. k. Gesellschaft der Aerzte zu Wien.' The
numbers given in the text arc based upon the records of 6213 cases of small-
pox. Of these f^2i7 occurred in persons who had been vaccinated, of whom
271 died; 996 occurred in individuals who had not been vaccinated, of whom
300 died. These data give the numbers stated in the text. — [Ed.]

TREATMENT. 263

In the early months of pregnancy, it generally causes abortion, and at
a later period, premature labour; but, when this occurs, the fcctus
does not invariably display any marks of smallpox. When this
complaint attacks lying-in -vromen, it constitutes a new source of
danger, superadded to a condition which, in itself, is apt to take an
unfavorable course.

Among men (who are more apt than women to drink to excess),
smallpox is particularly to be dreaded in persons who imbibe large
quantities of spirituous hquors, for the delirium potatorum often
developes itself in these patients, forming a dangerous compli-
cation.

Individuals previously rachitic, aneemic, or the subjects of tu-
bercle, are more severely attacked by variola than persons who
enjoy good health, and present none of these morbid conditions.

According to my experience, lastly, the fact of having previously
passed through the disease is to be enumerated among the most
unfavorable circumstances, in reference to the prognosis of small-
pox. I have repeatedly had occasion to observe, that persons who
had before been attacked by variola, and who presented the most
marked cicatrices, have died of this complaint when seized with it
for the second time in a severe form.

Among the complications of smallpox, those which are to be
looked on as most dangerous are the metastatic affections, in the
form of abscesses or gangrene.

Treatment of Smallpox.

Under this head, we have to consider separately the management
of the disease itself, and that of its complications and sequelse.

Uncomplicated variola passes regularly through its various stages,
and in the majority of cases terminates favorably, vntliout any treat-
ynent whatever. Its course is not in any way altered by the less
severe external influences, nor even by the simultaneous presence of
internal diseases, unless of some intensity. Hence, there can be no
question as to the employment of any remedies, except such as are
adapted rather to soothe tlie patient than to put a stop to the
morbid process ; and we must either give no medicine at all, should
such a course be compatible with the circumstances of the case, or
order simply some of the EmoUientia, Mucilaginosa, or Oleosa, which,

264 VARIOLA.

no doubt, serve to keep the mucous membranes in a moist condition.
Our duty is not so much to give our patient any positive prescrip-
tions, as to warn him vehemently against the employment of any of
the more energetic plans of treatment. Thus, the practice, once
customary, of bleeding during the stadium jirodromoruyn, with the
supposed object of favouring the development of the eruption ; the
administration of emetics and purgatives, to keep the prima, vice free
from all " sordes j " and the application to the skin of irritants,
such as sinapisms or vesicants, are alike unadvisable. These last,
indeed, are especially to be avoided, because, as I have already
shown, variolous pustules are developed in much greater numbers
on those spots which had before been (intentionally or accidentally)
exposed to irritation, than on parts which have not previously been
rendered in any way hyperccmic.

On the other hand, no objection can be made, upon either theo-
retical or practical grounds, to the employment of tepid baths, or
the cold douche itself, even in the stadium ßoritionis of smallpox.
For ex])erience has sufficiently ])roved that no ill effects whatever
are produced even by their repeated use.

We may, however, deviate from this expectant method of treat-
ment in certain cases of variola vera, in which the disease runs a
very protracted course, and in which quinine, the mineral acids, or
the bitters are indicated by the occurrence of rigors or by the per-
sistence of the secondary fever. The specifics once vaunted — among
which camphor, especially, played a prominent part — have not,
according to ray experience, the value which has been ascribed to
them.

Powerless as our medicines prove to be in controlUng the variolous
process, they are no less ineffectual to relieve those disagreeable
symptoms — such as salivation, or angina — which sometimes accom-
pany the disease. Thus, we have no remedy which can either pre-
vent the occurrence of salivation, or check it when present. It may,
indeed, be thought that this is to be effected, after coutmuing their
use for about a week, by gargles which either consist simply of
mucilaginous or astringent decoctions, or contain chlorate of potash,
alum, or tannin. But to those who are of this opinion, I may with
truth reply that, in cases of variola, I have invariably found these
affections to subside within the same space of time, or more quickly
still, when the mouth of tlie patient was simjily rinsed out at
intervals during the day, or even Avithout any treatment whatever.

TREATMENT. 265

But while I admit that no treatment is required by cases of small-
pox which run the regular course of the disease, I am yet far from
being satisfied with a mere expectant method in the protracted
and severe forms of variola vera. On the contrary, as I shall imme-
diately explain, I see fully what should be the aim of a rational
treatment of variola, although my attempts to attain this object have
hitherto been unsuccessful. As I have already stated, the course of
smallpox may always be divided into two distinct periods. In the
first of these,, we have to deal only with symptoms which are called
into existence directly by the variolous process, or (if we choose to
call it so) by the variolous dyscrasia. Among these symptoms are
the special forms of efflorescence, which appear on the skin and on
the mucous membranes. But, after about the tenth day, when the
disease has reached its height, it varies in its course in different
instances, and may take either of two directions. In one case, its
course is favorable ; the contents of the pustules dry up, and we are
warranted in anticipating the recovery of the patient. In another
case, the purulent matter remains for some time fluid ; and under
these circumstances a fatal termination frequently takes place, from
the formation of metastatic deposits. Kow, the only way of ex-
plaining this occurrence is to suppose that the pus, when its desic-
cation is impeded, undergoes a putrefactive fermentation ; that this
decomposing organic fluid, being in contact with the vessels of the
cutis, is absorbed by them, and enters the circulation ; and that
thus is produced the affection known at the present day by the
name of pyaemia. It may fairly, then, be the aim of the medical
art so to bring variola to a termination, that the process of decom-
position of which 1 have spoken may be rendered innocuous. Now,
there are two ways in which this might conceivably be effected ; on
the one hand, by inducing the quickest possible desiccation of the
pustules ; on the other hand, by removing their contents with as
little injury to the epidermis as may be, and so as not to expose the
cutis or permit the access of air.

It was formerly the practice, in cases of smallpox, to employ
caustics (das Ectrotisiren) with the hope of favouring the desiccation
of the eruption, which I have stated to be one of the objects of a
rational treatment of the disease. For this purpose, a stick of
nitrate of silver was introduced into every individual pustule, and
rubbed forcibly over its base, so as to coagulate the albuminous
contents. But, although this can be done in cases of varicella or

266 VARIOLA.

varioloid, it is quite impossible to carrj out such a practice in the
variola vera, when the efflorescence is present in large quantity, and
especially in the confluent form of the disease, in which the whole
surface of the skin is covered uninterruptedly with the pustules.
Tliis treatment would, under such circumstances, give the patient so
much pain, that we should have to fear the most injurious effects on
the nervous system. The application of nitrate of silver is, in fact,
impracticable in those very cases which are the most dangerous.
Moreover, experience has shown that it fails in attaining the object
aimed at, for a fresh exudation, which itself becomes purulent, is
found to accumulate beneath the eschar produced by the caustic. This
procedure, therefore, is no longer adopted.

Other methods, besides this, have been tried, with the object of
causing coagulation of the contents of the pustules. Thus corrosive
subhmate, alcohol, and tincture of iodine, have been applied locally,
and electricity also has been employed. No success, however, has
followed these modes of treatment.

Now, we find from experience, that, on the mucous membranes,
the efflorescence never becomes so fully developed as on the surface
of the skin. In the former situation, the contained fluid does not
become purulent, and crusts are never formed. This peculiarity can
be attributed only to the circumstance that the mucous surfaces
are perpetually kept moist (macerirt) by their secretion. Hence it
is natural to suppose, that if the roofs of the smallpox pustules
on the cutaneous surface can be kept constantly soaked by fluid
in a similar way, the same result will be attained ; that is, the fluid
contents of the eruption will be allowed to escape earher than
would otherwise be the case.

With the object of effecting this result, I have made certain
experiments upon individuals affected with smallpox, covering one of
their extremities with wet cloths, while, for the sake of comparison,
the corresponding parts of the opposite limb were left dry. These
observations proved that this procedure is, at any rate, comfortable
to the patient, although it did not do all that I desired. I have
found it particularly useful to apply this treatment to the soles of
the feet. As I have already stated, when these parts are kept dry,
the formation of numerous smallpox pustules upon them produces
great pain, in consequence of the thickness of the epidermis, which
is with difficulty raised by the exudation, and thus causes a counter-
pressure on the cutis. But when the feet are wrapped in wet cloths.

TREATMENT. 267

covered with oil-skin or thin gutta perclia, no disagreeable sensations
are complained of.

These experiments matured in my mind the project of devising an
apparatus by means of which the patient could be kept in water of
the temperature of his body, continuously, day and night, throughout
the whole course of the disease. My object was, by thoroughly
soaking the pustules, to favour the escape of their contents, and, at
the same time, to prevent the access of air, so as to render it im-
possible that any decomposition of the pus should take place. I shall
refer more fully to this apparatus when speaking of the treatment of
burns.

The apphcations formerly recommended for the purpose of pre-
venting the formation of cicatrices after smallpox, seem to have been
directed to the same end, that of softening the roofs of the pustules.
Among the remedies employed with this object, were the following :
the simple mercurial plaster, the Empl. mercuriale de Yigo,^ the
rind of bacon tied over the face, the simple Cerat, Cetacei, the Ung.
Plumb. Acetat., and cold cream {creme celeste). But neither these
applications, nor even corrosive subhmate, the tincture of iodine, or
the spirit of camphor, succeeded in every case in preventing the
occurrence of ^^ pitting.'" Indeed, it is obvious, from what has been
stated above, that it could not be otherwise. For when the pustules
are deeply seated, and imbedded in the cutis itself, the loss
of substance caused by the variolous process cannot be obviated
by any method of treatment. The apparent efficacy of these vaunted
remedies may be easily understood, when we reflect that under no
circumstances is every smallpox pustule followed by pitting. Indeed,
of one hundred patients affected with the variola vera, hardly fifty
will afterwards present cicatrices ; and in varicella and the varioloid,
either none at all are formed, or a few only are left as proofs that
the individual has passed through the disease.

Thus, then, whatever remedy is made use of with the object of
preventing the pitting, it will be found, if the same treatment is
carried out in all cases without exception, that many of the patients
after recovery present no cicatrices. That this is the case is, indeed,
proved by the fact that in the last century, before vaccination was

^ The Empl. de Vigo was a farrago, containing a large number of substances.
Twenty parts of this plaster, with three parts of mercury, previously extin-
guislied by trituration witli one part of oil of turpentine, constituted the Empl.
mercuriale de Vigo. (V. Jourdan, op. cit., ii, p. 41.) — [Ed.]

268 VARIOLA.

practised^ and when most people, as is well known, were attacked
by smallpox, every one was not pitted, but only those in whom the
disease affected the deeper strata of the skin. It certainly does,
however, give the patient great relief, to keep the skin of the face
covered with some emollient substance from the stadium eruptmiis
till the crusts are formed. But for this purpose the application of
bacon or some simple ointment does just as well as any of the
compound ointments, tinctures, or lotions.

It Avas for a long time firmly believed, that the development of
variolous pustules on the conjunctiva could be prevented by using
collyria from the very commencement of the disease ; these coUyria
being either applied externally to the eyelids by means of compresses,
or dropped into the eye. This notion, however, turns out to be
unfounded. For, in no one of the cases of smallpox (far exceeding
5000 in number) which have come under my care, have I observed
any pustules on the surface of the eye, although I have had recourse
to no prophylactic treatment whatever. The conjunctival fluid seems
to act here in the same way as the secretion of the mucous mem-
branes, and, by keeping the surface moist, to prevent altogether
the formation of pustules, or, at any rate, to make them at once
abort, and die away.

The treatment of the complications of smallpox is that of the
internal or external disease, which is present in the particular case.
These affections require the adoption of the same remedial measures,
as if they were independent of the variolous process. Thus, any
abscesses or furuncles which may appear should be opened as early
as possible, and the contents having been discharged, the closure
of the cavity of such abscesses should be favoured by the appli-
cation of pressure. Inflammatory afiections of the skin — erysipelas
and pseudo-erysipelas demand an antiplilogistic treatment; but
leeches should not be used, nor scarifications; the application of
bags of ice, or of ice-cold wet rags (Eisumschläge) being all that is
necessary. Lastly, gangrene or diphtheritis must be treated on the
ordinary principles of surgery.

It remains for me to discuss in detau the hygienic management
of smallpox. In this, and indeed in every complaint, fresh air
and a moderate temperature are above all things beneficial. The
fear lest persons affected with variola should " catch cold " led our
forefathers to place them in rooms which were kept at a high tem-
perature, and in which no ventilation whatever was allowed. Indeed,

TREATMENT. 269

they even forbade changing the patient^s linen. But I have satis-
fied myself, on the contrary^ that the more severe the disease the
greater the need of fresh and even cool air, of frequently changing
the patient^'s bed- and body-linen, and of carefully cleaning the sur-
face of his body. In this way his sufferings may, in fact, be con-
siderably lessened.

The supposed retrocession of smallpox has never occurred within
my experience, even when the patient has been exposed to the
most severe weather throughout the whole course of the disease.
In fact, I have seen several instances in which persons have remained
in the open air through every stage of the exanthem, and have
sought admission into the hospital only during the stadium decrus-
iationis ; and I have had to treat one patient who had been com-
pelled, while suffering from a severe attack of variola vera, to make
a twelve days' journey on foot. This occurred, moreover, during
winter, when the temperature was as low as 10° Fahr. (—10° E.).
Notwithstanding his lamentable condition this poor man found
relief nowhere, till at last the hospitable portals of the General
Hospital of Vienna offered him a place of refuge. When this
patient was admitted his body was found covered with crusts formed
from, variolous pustules.

The hydropaths (Naturhydropathen) have submitted cases of
smallpox to a treatment which would never have entered the head of
a regular physician. These practitioners have placed patients suf-
fering from the disease in unwarmed rooms, in houses built merely
of planks, have " packed " them repeatedly in wet cloths, and have
allowed them to bathe several times a day in water of a temperature
of 36° — 41° Eahr. (£° — 4° E.) . Yet even these proceedings have not
caused a metastasis of the contents of the smallpox pustules to more
important organs. In spite of the treatment the patients have re-
covered.

Acting upon a knowledge of this fact, I have prescribed cold
douche baths to several patients affected with smallpox, and have
kept them out of bed from the commencement of the disease until
the formation of crusts was completed ; nor have I ever seen any ill
effects produced by these measures.

Now I do not consider this practice to be either humane or appro-
priate in cases of smallpox ; on the contrary, it is in the highest
degree unpleasant to persons suffering from a severe illness ; and,
therefore, I do not recommend its adoi)tion by others. But I think

270 VARIOLA.

that I have proved positively that it is not possible to cause the re-
trocession of variola, or to do the patient harm, bj^ exposing him to
the influence of either cold air, or cold water, or, in other words, to
the danger of " catching cold."

A person affected with smallpox, then, should be kept in his
usual bed, in a well-ventilated room, and at a moderate temperature
(6i° — 64° Pahr.). The bed- and body-linen should be frequently
changed ; and he may be allowed as much cold, cool, or lukewarm
fluid as he may be inclined to drink.

The nature of his diet must depend chiefly on the presence or
absence of fever. An individual suffering from variola vera will,
for the most part, feel no desire to take food before the tenth day of
the disease. But, in varicella, there is generally a good appetite
after the fourth day, that is, at the end of the stadium prodromoruvi.
In this matter the inclinations of the patient may be considered ;
if he is free from fever, we may give him light meat-broth as soon
as he can take it, afterwards allowing other well-cooked, nutritious
kinds of food, according to the state of his appetite. In reference
to prognosis, the fact that food is taken from the first, is to be re-
garded as a favorable sign. Indeed, when one considers how great
is the waste of the vital fluids caused by the variolous process, it is
easy to see that then: replacement by the ingestion of nourishment,
must contribute very greatly to the restoration of health.

When the disease runs its ordinary course, there is no necessity
for the patient to take baths or to be washed. But, during the
stadium decrustationis, a bath always gives him great comfort.

It is clear, lastly, from what has been said, that it is quite
unnecessary to subject patients convalescent from variola to a fur-
ther quarantine of a month or six weeks. As soon as the crusts
are all detached, and the patient has been washed or has taken a
bath, he may with safety be dismissed from treatment ; to him, at
any rate, no ill consequences will ensue. But as m'c do not pre-
cisely know the limits, as to time, of the contagiousness of small-
pox, nor how soon the patient ceases to be a source of danger to
those with whom he comes in contact, it will be more judicious, so
far as others are concerjicd, to keep him isolated a little longer,
perhaps for a fortnight after the termination of the disease.

CHAPTER XI.

VACCINIA, OR COW-POX.
(CLASS IV.— ACUTE, CONTAGIOUS, EXUDATIVE DERMATOSES.)

More than a century since, it first came under the observation of
physicians, and of philosophers (Naturforscher) also, that when the
smallpox prevailed in human beings similar eruptions appeared on
the udders of cows. Thus, as far back as the year 17 13, we find a
treatise 'De lue Yaccarum,^ written by Salger; and in 1765 Sutton
and Eewster gave a description of the cow-pox, and drew atten-
tion to its protective power against smallpox. In the years 1769
and 1 781 we find further mention, at Göttingen and at Mont-
pellier, of the properties of the virus of cow-pox; and, in 1791,
a man named Plett, a schoolmaster in Holstehi, is said to have
inoculated two children with this virus, and to have thereby
protected them from smallpox. But it was Dr. Jenner who, in
1796, after long-continued preliminary investigations, made the first
decisive experiment, by inoculating the arm of James Phipps, a boy
eight years old, from the hand of a milkmaid, named Sarah Nelmes.
Dr. Jenner published his results in the year 1798. Vaccination
soon met with general acceptance, the practice being diffused chiefly
by De Carro, Oslander, Sacco, Woodville, Gassner, Neumann, Thiele,
Ceely, and others. These writers have also demonstrated the iden-
tity of vaccinia and variola, by observations on man and on the
lower animals, and by the performance of retrovaccinations.

Even within the first few years after the introduction of vacci-
nation some of those persons, on whom the operation had been
performed, were attacked by variola; so that it at once became
evident that the protective power of vaccination is not absolute, as
had been hoped by its discoverers and by those who first wrote upon
it. But even then it was obvious that the occurrence of smallpox
in vaccinated individuals is quite exceptional ; that the course taken by
the disease is, in such persons, much less severe, and that the pustules
are much less numerous; and, lastly, that a fatal termination is

272 VACCINIA.

very rarely observed. Hence, in order to maintain in its integrity the
doctrine of tlie protective action of vaccinia, physicians came to ex-
plain these cases by referring them to a disease which they termed
varioloid, and which was supposed to be essentially distinct from,
although similar to, variola.

During the time which has since passed, however, the question of
the protective power of the cow-pox has been so fully tested, that we
are now able, independently of any preformed opinion, to draw con-
clusions based directly upon numerous observations and upon statis-
tical data. These conclusions are altogether favorable to vaccination.
A few sceptics have, indeed, arisen here and there who have tried,
by their suspicions and cavillings, to bring into discredit this bless-
ing to humanity. But the sound sense of mankind in general has
expressed itself so decidedly in favour of vaccination, that there is
110 ground for fear that due advantage will not be taken of this
beneficent discovery.

It has long been a moot point, whether vaccinia is identical with
variola, or merely allied to that disease ; and I think that I can best
answer the question by dra^ang attention to the following facts.
Numerous and repeated experiments have shown that the smallpox
virus, when taken from man, and transferred to one of the lower
animals (that is, either to a cow, or to a horse, ass, goat, pig, dog,
or ape), gives rise to an affection resembling the eruption of variola
in its form, and also in the changes which it undergoes. Moreover,
retro-inoculations (from one of the lower animals to man) have
given rise, in the human subject, to a distinct smallpox efflorescence,
although it is true that the entire disease has never been reproduced
in this way. The virus, therefore, is essentially the same, being
merely rendered milder by passing through the animal organism.

Again, if we compare tlie course of the vaccine eruption in the
cow and in the human subject, with the smallpox efflorescence, we
find so close a resemblance between the two affections, so perfect a
uniformity, both in the structure of the vesicles or pustules, and
in their periods of development and involution, that their identity
is perfectly obvious.

Tor, if the contagious fluid derived from the vaccine vesicle of
the cow be brought, either by accident or intention, in contact with
the human skin by any one of the methods hereafter to be described,
the following result is observed. In the first place, there is an in-
terval of three days between the time of inoculation and the appear-

VACCINIA. 273

ance of the first symptoms of reaction, during which period no sign
of any change in the skin is to be detected. But on the fourth
day the epidermis becomes raised, so as to form a small papule ; in
the course of the fifth and sixth days, the quantity of fluid in its
interior increasing, the papule passes into a vesicle ; and this, during
the next tvro days, enlarges, attaining its full development on the
eighth day from that on which the inoculation was performed.

The red areola, which, as early as the seventh day, appears at the
circumference of the vesicle, is an indication that the fluid in the
interior of the vesicle is beginning to contain a greater number of
pus-cells; and from the ninth day up to the twelfth its distinct
yellow colour shows that the contents have become completely
converted into pus. Prom this time it begins to undergo desic-
cation, drying up gradually from the centre to the periphery, and
thus forming a crust which remains adherent till the twenty-first
day.

Now, if we compare this description with that of a moderately
severe case of smallpox, we find that the pustules, in each of these
aft'ections, pass, in equal periods of time, througli changes which are
in every respect the same. Indeed, we even observe, in each in-
stance, similar modifications of the ordinary course of the eruption ;
this being sometimes of shorter duration, and sometimes more pro-
tracted. Again, an examination into the anatomical structure of the
smallpox pustules, as compared with that of the pustules of vaccinia,
shows that they are identical. In regard to this point, I have
only to refer to the description which I gave when speaking of
variola, and which is perfectly applicable to the efflorescence of cow-
pox also.

These facts, which prove the identity of smallpox and vaccinia,
also enable us to understand how it is that vaccination possesses a
power of protecting against smallpox, and yet that this power is
(Mativ) not absolute. Por, just as we find by experience that the fact
of having once passed through an attack of variola is itself but a partial
(relativ) security against a second infection, so must it necessarily
be with the cow-pox also ; if, indeed, its protective power be not
still less complete, in consequence of the fact that vaccinia is a
milder disease than smallpox. It is, however, this very circum-
stance which renders the cow-pox suitable for inoculation, making it
possible for us to perform vaccination without exposing the patient
to the dangers of ordinary variola in the same way as when the

274 VACCINIA.

virus of that complaint is transferred directly from one human being
to another. Guided bj these views^ then^ M'e shall not expect
vaccinia^ the milder variety of the disease, to afford a protection
against smallpox more absolute than we are in the habit of looking
for from severe variola itself.

When this method of preventing smallpox was first proposed, at
the end of the last century, the lymph employed was derived either
from vesicles existing on the udders of cows, or from those which
are found in horses affected with the " grease /^ the fluid obtained
from the latter source being itself sometimes first transferred to the
udder of a cow, instead of being used directly for inoculation in the
human subject. Yaccine vesicles having, in one or other of these
ways, been obtained in man, their contents were removed eight days
later, and the lymph thus procured was transferred to other per-
sons who required to be vaccinated, after which they, again, afforded
a fresh supply, and so on. This jjractice led, at the time, to an
observation, which has been confirmed by subsequent experience,
namely, that when a human being is inoculated with lymph taken
immediately from one of the lower animals the operation is
less certain to succeed than when the lymph is merely transferred
from one person to another. Moreover, in the former case the
pustules which are produced are attended by far more severe symp-
toms of reaction than when the lymph has previously been humanised
(humanisirt) .

These observations suggested the further inquiry whether more
perfect security from smallpox is offered by vaccinating with lymph
taken directly from the cow, or by employing vaccine matter which
has already been transmitted in succession through several human
beings. "We are enabled to answer this question with the utmost
certainty by the results obtained at the principal vaccine institution
of Vienna. Some of the lymph used in this establishment has been
carried down without interruption from the first vaccinations prac-
tised by De Carro at the beginning of the present century; and
now, at the end of sixty years, this matter still " takes " just as well
as before, and its protective action against variola is as complete as
that of lymph which has, in the mean time, been derived from fresh
inoculations with matter taken from the udder of the cow. In this
institution a most exemplary system prevails, for in each room the
same lymph is always used, and, during more than ten years.
Dr. Friedinger has employed, each vaccinating day, matter from

VACCINIA. 275

only one original source. Hence the results arrived at are, in
every respect, of a very conclusive kind.

It appears to me, therefore, that lymph which has already been
humanised should, at the present day, be used for vaccination rather
than that derived directly from the cow. For the former takes
easily, is followed by a comparatively slight reaction, and is readily
obtained ; while the latter is uncertain in its effects, and gives rise
to much more intense inflammatory action. The principal reason
which has induced people to prefer original cow-pox lymph to
that which has passed through the human system, has been the fear
that other diseases besides vaccinia might possibly be transferred to
the patient by vaccination. But experience has now shown that no
other morbid conditions or dyscrasi^e can be thus introduced. In-
deed, no one, when he has unintentionally become inoculated with
the syphilitic poison, fancies that he may, at the same time, have
acquired scrofula or gout; but it is just as probable that this should
occur as that any other disease should be conveyed by vaccination
besides the mild form of smallpox, which it is the object of the
operation to transmit. This question has, in fact, been submitted
to direct experiment, by using for inoculation a mixture of chancrous
pus and vaccine virus; the result of employing this combination
being that sometimes a chancre was produced, sometimes a vaccine
vesicle, but never any modification of them or any third affection.
For information upon this matter, and also for the elucidation of
other points, of which I shall hereafter have to speak, I may refer
the reader to the English blue-book,^ of which the conclusions are
based upon opinions and statistical data derived from all parts of
Europe.

Another point, with reference to which the views of medical
men are divided, is the question whether vaccination should, or
should not, be performed while a child is very young. But, if we
take into account the danger of smallpox in little children, and the
diminished severity of the disease in those who are older, we cannot
but advocate the practice of vaccinating during infancy. This con-
clusion is further strengthened by the fact that the operation is per-
fectly free from danger, even in children of the most tender age.
In the principal vaccine institution of Vienna infants are often vac-
cinated when only ten days or a fortnight old, without any injui-ious

1 'Papers relating to the History and Practice of Vaccination,' by John
Simon, Loudon, 1857.

276 VACCINIA.

effects being observed. In a child^ healthy in other respects, and
suckled by its mother or by a nurse, this operation gives rise to
no unpleasant symptoms whatever, with the exception of slight
febrile disturbance, which, however, subsides, at the latest, within
from six to twelve days after inoculation.

I am, then, a decided advocate for early vaccination, and advise
that it should, in general, be performed when the child is a fort-
night old.

Again, it is shown by the experience of our vaccine institution
that the season of the year does not affect, to any great extent, the
results of vaccination. In fact, both successful and unsuccessful
cases are observed at aU seasons ; nor can we in any way attribute tlie
result to the time of year at which the operation is practised. The
same thing, however, occurs with vaccinia as with many epidemic
diseases. There are periods when the contagion of variola is very
active, and others during which it is much less so ; and, in the same
way, vaccination sometimes succeeds in every case, while, at other
times, frequent failures are met with ; but neither the time of the
year nor the weather has anything to do with these differences. We
may, then, perfonn vaccination at any season.

The !paTts of the body usually chosen for this operation are, of
course, such that the cicatrices which follow may be covered by the
clothes, so as not to be visible under ordinary circumstances ; but
it does not matter in any other respect what spot is selected. Vac-
cination is, as is well known, most commonly performed on the upper
third of the arm. When, however, the child is affected with a
nsevus, this may be chosen as the seat of the operation. In this
case numerous punctures must be made side by side, and sufficiently
close to one another that the subsequent cicatrices may coalesce,
and that, as a result of the formation of these cicatrices, the morbid
structures may become atrophied.

Another matter of very little importance is the number of punc-
tures which are made, the only reason for the ordinary practice
of inoculating at several points being to ensure that at some of
them the operation may succeed and produce a vaccine vesicle. I
do not believe that it is necessary to obtain several of these vesicles
in order to give an additional degree of security against smallpox.

As is well known, there have been from the first many different
methods of vaccinating. Some operators have applied small blisters,
and have afterwards put portions of the vaccine crusts on the sur-

VACCINIA. 277

face thus deprived of its cuticle, or have rubbed into it the vaccine
lymph. It is evident that this process must give rise to much more
severe reaction,, and must produce vesicles of far greater extent, than
that which is usually adopted. Others, again, have made use of an
instrument resembling a drawing pen, and consisting of two parallel
limbs with cutting extremities, between which the lymph is taken
up. In employing this instrument the vaccine matter is introduced
beneath the cuticle by a horizontal or vertical incision. The wound
which it causes is, however, larger than is necessary, and the object
aimed at is not attained without causing considerable pain in the
part which is the seat of the punctures.

The most satisfactory method of vaccinating hitherto proposed is
that by means of a lancet made for this special purpose, and having
one surface convex, the other slightly hollowed, and presenting a
groove, to which a drop of the lymph adheres.

In employing this instrument it is necessary to introduce its point
beneath the cuticle to the depth of at least a line, holding it hori-
zontally with the convex surface downwards and the concave surface
upwards. When the epidermis has been penetrated the lancet must
be turned round, so that its convex surface shall look upwards and
its concave surface downwards towards the cutis. Tlie thumb of the
left hand (supposing that the right is used to hold the instrument)
must then be placed over the wound, and made to exert a gentle
pressure upon it ; and the lancet is then to be withdrawn, the lymph
being thus, as it were, ^ciped off into the cutis. When vaccination
is performed in this way it does not matter whether a drop of blood
does, or does not, escape from the puncture; nor does it make any
difference whether we allow the clothes to be at once put on, or leave
the part exposed for some time.

There is also another method of vaccinating, which is, however,
much less certain to succeed than that which I have been describ-
ing. Hence it is only when that method of performing the operation
is inapplicable that this should be adopted. It consists in col-
lecting the lymph upon " points " made of bone (Beinlanzetten) and
allowing it to dry. These points are subsequently introduced into
the punctures made by an ordinary lancet, and are left in them for
some time.

In performing this operation it is always best to transfer the
lymph directly from one patient to another, using for this purpose
the fluid found in the vesicles on the eighth day after vaccination.

278 VACCINIA.

As, however, we cannot in all cases do this, we have to collect and
endeavour to preserve the vaccine matter. For this purpose, as is
well known, small glass tubes, provided with capillary necks, are
employed. "When one of these tubes is to be used, its stem is first
warmed in the flame of a candle, so as to expand the air which it
contains. The vaccine vesicle having been punctured, the open
extremity of the tube is next introduced into it, and quickly becomes
filled with the lymph. Tlie capillary end is then rapidly sealed in
the flame. Vaccine matter, thus collected, may be preserved in a
cool place for a very long time without loss of its power of protect-
in o- a"-ainst smallpox. When we want to use it we haA^e only to
break off the end of the tube with our fingers, or with a pair of
scissors, and to hold the stem over the flame of a candle, so as to
expel the lymph. This, however, must be done with some care, for
the sudden or long-continued application of heat may make the
vaccine matter quite inert. Indeed, exposure to a temperature of
146° Fahr, destroys the contagious principle.

Irregular forms of Vaccinia.

The local efl'ects of vaccination do not, in all cases, develop
themselves in the way which I have described as being most gene-
rally observed. On the contrary, vaccinia, like smallpox itseK,
presents numerous irregularities. Of these varieties some concern
the cutaneous appearances alone, being, in fact, the local modifica-
tions of vaccinia ; whereas others are to be regarded as symptoms
of a general reaction, produced by an absorption of the contagious
matter into the blood.

It is impossible not to recognise the similarity between the irre-
gular forms of vaccinia and those of variola. For, in the latter
disease also, we have to deal with local and with general modifica-
tions of the normal course; and in it, as in the case of vaccinia,
the local appearances consist, sometim.es in an anomalous develop-
ment of the pustules, sometimes in the presence of some other
affection, such as erysipelas or gangrene.

IRREGULAR FORMS. 279

I. Local Modifications of Vaccinia.

{a) Variola Vaccina atrophica. The stunted or warty form of
cow-pox. (Steinpocke.)

By this term is understood a condition in which the vaccine
vesicle does not fully develop itself, but remains in the papular
stage, or, if it passes into a small vesicle, never comes to contain any
considerable quantity of fluid, as it does under normal conditions.
In these cases, m fact, the affection quickly dries up and forms
a little, brownish-yellow, wart-like scab, which, when it becomes
detached, leaves behind a small cicatrix. This imperfect, stunted
form of vesicle, nevertheless, sometimes contains an inoculable fluid,
which, when transferred to a more vigorous organism, may take, and
give rise to regular vaccine vesicles. Hence it is evident that this
modification of the vesicle produced by vaccination depends on some
peculiarity in the individual vaccinated, rather than on any defect in
the lymph employed. In some instances, however, the contents of
these aborted vesicles cannot be used for further inoculations.

(Ä) Roseola Vaccina.

This affection has been already^ described among the hjqjersemise
of the skin ; but it requires to be enumerated as one of the varieties
of vaccinia, and, therefore, I again refer to it in this place.

As is well known, it forms a diffuse rash, affecting the arms of
those who have been vacciuated. It makes its appearance from
the third to the eighteenth day after the operation ; and, after the
contents of the pustules dry up, it subsides without leading to any
further effects.

{c) Variola Vaccina herpetica. (Eczempocken oder Krätzpocken of
German authors.)

On the third day after vaccination has been successfully performed
there sometimes appear at the seat of the operation a number of

1 Vide p. 58.

280 VACCINIA.

vesicles, placed close to one another, and filled Avitli a watery fluid.
This affection is attended with severe itching. The contents of the
vesicles soon escape, and afterwards there is a continual oozing from
the surface. The itching, which makes the child perpetually try to
scratch or rub the part, and the fact that the clothes are constantly
sticking to the skin and being torn off from it, favour the develop-
ment of an eczema, which presents a more or less infiltrated base,
and is surrounded by an inflammatory areola of greater or less
extent. This affection often gives rise also to a sw^elHng of the
neighbouring axillary glands.

This form of vaccinia is observed chiefly in children who are
weakly, rachitic, scrofulous, or aupemic. But it may present itself
in any child if the vaccine vesicles are accidentally broken, so that
the fluid escapes from their interior before being converted into pus.
Experience does not confirm the supposition that this affection is
especially attributable to the presence of other chronic cutaneous
complaints, such as scabies or eczema.

(d) Variola Vaccina bullosa, Pemphigoides. (Blasenpocken.)

Li this modification of vaccinia there is developed, instead of the
usual papule or vesicle, a bulla, containing a transparent fluid, and
having a reddened margin. This appearance may present itself
either at all the spots Avliich were the seat of vaccination or at
some of them only. When the bulla Ijreaks, its contents generally
dry up into a thin crust, which, on falhng off, leaves behind it no
scar. In some cases, however, there arise beneath the crusts ulcers,
which destroy the surrounding tissues, and, when they heal, give rise
to very considerable cicatrices.

The fluid derived from these bullae is not fit to be used for further
inoculations.

The bullous variety of vaccinia is^ for the most part, merely spora-
dic ; but, during the year 1 836, I had an opportunity of observing
it in the FoundHng Hospital of Vienna, in a quasi endemic form.
This fact is also mentioned by Zöhrer^^ in his work upon the subject
of vaccination.

• 'Der Vaccineprocess und seine Krisen,' Wien, 1846, p. 117.

IRREGULAR FORMS. 281

(e) Fariola Vaccina furunculosa. (Vaccinefurimkel.)

In this form of the affection red tubercles, as large as peas, appear
at the spots which were the seat of vaccination. These tubercles
afterwards suppurate. They correspond to ordinary follicular furun-
culi. The pus which they contain cannot be employed for the pur-
pose of vaccination. It dries up into thin scabs, which, when they
fall off, leave behind them no cicatrices.

This modification of the vaccine vesicle arises principally when the
operation was badly performed, either with " points," or with the
instrument above described (Impffeder), or by the method of
longitudinal incisions ; but it may present itself even after vaccina-
tion with the ordinary lancet, when this is allowed to penetrate too
deeply into the corium.

{/) Erysipelas Vaccince, Variola Vaccina erysvpelatosa. (Vaccine-
Erysipel.)

This affection makes its appearance from the seventh to the
tenth day after vaccination, at the time when the contents of the
vesicles are first becoming opaque and purulent, and when eacli of
them is surrounded by a more or less extensive areola, even in cases
which take the normal course. It consists in the formation of a
broad red ring, which rapidly increases in extent ; it is attended
with swelling, tension, and pain ; and it presents the usual charac-
ters of an erysipelas. Afterwards it sometimes spreads downwards
to the forearm, or even as far as the fingers, and in the opposite
direction to the axilla and chest. It will be readily understood, from
the nature of erysipelas, that concomitant and febrile symptoms
Avill also be present, according to the extent and severity of the
complaint.

This affection probably arises in very much the same way as that
form of inflammation which is often set up in adjacent parts of the
skin by the presence of pus or matters in a state of decomposition,
when retained for some time beneath the integument, so as to be
absorbed into the lymphatics or veins. The erysipelas vaccina', is
generally ascribed to the chih^s having caught cold, or having been

282 VACCINIA.

fed with too rich and nourishing breast -milk. But I cannot admit
that it owes its origin to these or to any similar conditions.

On the other hand, the following circumstances are to be regarded
as being really among the predisposing causes of this disease : — The
crowding together of a great many children into a confined space,
as, for example, in foundling hospitals ; neglect of cleanliness ; and,
lastly, a certain " constitutio epidemica,^^ which is apt to prevail
during the months of April, May, October, and November.

{g) Variola Vaccina ulcerosa. (Vaccinegeschwür.)

In cases in which the vaccine vesicles have developed themselves
in the ordinary manner up to the eighth or tenth day, one some-
times finds that, instead of the contained fluid drying up and form-
ing crusts, the pustules rupture and allow their contents to escape,
nnd that ulcers then make their appearance. These ulcers spread
both deeply and at their borders. They give rise to pain or itching,
and are attended with febrile symptoms and with great restlessness,
sleeplessness, and loss of appetite.

This variety is most frequently observed when the virus was de-
rived immediately from the cow ; but ui some cases it appears even
after vaccination with l}Tnph which has already passed through
several human beings. The fact that on the udders of cows similar
vaccinal ulcers are sometimes met with is in favour of the suppo-
sition that this affection is due to the settmg up of a very intense
morbid process in the skin of the part, and not (as might be sup-
posed) to any particular idiosyncrasy of the person vaccinated, or to
any specific change in the blood.

{h) Gangrene. (Gangrän an den Impfstellen.)

Bednar^ has given an instance of this, in the case of a weakly in-
fant, thirty-three days old. In this child the crusts became con-
verted, on the twenty-fifth day after vaccination, into^a black, foetid,
gane:renous eschar. At the same time diarrhoea and bronchial
catarrh set in, and sloughing bed-sores formed, and, in consequence,
the child died on the fifth day from the commencement of the
gangrene.

'Die Krankheiten der Neugebornen,' &c., Wien, 1853, s. 123.

IRREGULAR FORMS. 283

2. Modifications of Vaccinia affecting the By stem generally.

{(() Vacciniol(V. (Nebenpocken.)

In addition to the cow-pox pustules which dcA'elop themselves in
the ordinary way at the seat of vaccinatioUj an eruption of a similar
kind sometimes makes its appearance on other parts of the body.
This affection resembles a varicella. The pustules are more or less
numerous ; they may arise either at the same time Avith, or subse-
c[uently to^ those caused directly by the operation, and afterwards
run their course simultaneously with them. It is said that even
after the disappearance of the regular vaccine pustules a similar
efflorescence may appear, constituting, as it were, a relapse of the
complaint.

Medical men who practise vaccination (Impf ärzte) advise that the
contents of these pustules should not be used for further inoculations.
For my part, I would venture to express the provisional opinion,
founded on theoretical considerations (unmaassgebliche, subjective),
that these cases ought, perhaps, to be regarded as instances of
varicella occurring in persons who have been vaccinated.

ip) Vaccinal Fever. (Vaccinefieber.)

Between the seventh and ninth days after vaccination febrile
disturbance of a more or less severe character sometimes sets in,
manifesting itself by acceleration of the pulse, increased heat of skin,
sleeplessness, loss of appetite, great thirst, &c. According to some
observers, catarrhal symptoms (such as cough and hoarseness), and
even repeated attacks of vomiting, have also been present in these
cases. This affection varies greatly in severity ; the symptoms may
be so sHght that they remain unnoticed ; whereas, in other instances,
they attain rather a high degree of intensity. When it runs its
ordinary course, this febrile state is of very short duration, but
in those cases in which it is associated with other anomalous con-
ditions (such as erysipelas, furunculosis, or gangrene), it is more
protracted, and of greater importance. It must, however, be borne
in mind that all kinds of febrile complaints are just as likely to
appear in persons who have, as in those who have not, been

284 VACCINIA.

recently vaccinated ; and consequently that attacks of fever occur-
ring after vaccination lias been performed are not necessarily to
be set down as being effects of that operation.

This complaint is commonly observed in infants at the breast,
presenting itself when the vaccine vesicle has just attained its full
development, or, more i-arely, while the crusts are being formed.
Its chief symptom is the frequency with which the bowels act, the
evacuations being curd-like or of a yellowish-green colour, and gene-
rally fluid, though they may sometimes consist of ordinary fsecal
matter.

At the same time, aphthae often make their appearance on the
mucous membrane of the mouth. These symptoms are unattended
with danger to the cliild, and generally subside quickly under careful
dietetic management.

{d) Diseases of the Glandular Organs.

Swelling of the parotid and submaxillary glands sometimes occurs
after vaccination, and is attended with rather abundant salivation.
Affections of the lymphatic glands of the neck and axilla are also
met with under the same circumstances.

CHAPTER XIL

ON THE POLYMORPHOUS ERYTHEMATA.'

(CLASS IV.-ACUTE, NON-CONTAGIOUS, EXUDATIVE
DERMATOSES.)

I. Erythema exudativum.
A. 3rythema exudativmn multiforme.

WiLLAN speaks of six varieties of erythema, which is one of the
diseases of the skin included in his third order, the exanthemata or
rashes. Of these varieties the firsts which he terms the E. fugax,
is described by me among the hypersemisBj^ as belonging to that class
of affections. The second, to which Willan gives the name of
E. lave, is not, in my opinion, a peculiar cutaneous affection, but is
merely a simple erythema {E. fugax), presenting itself on the skin
of parts which are oedematous. Hence it only remains for me to
speak, in this place, of the E. marginattmi, E. paimlatum, E. tuber-
culatum, and E. nodosum. Certain authors, however, have men-
tioned other forms besides these. Thus, Rayer describes an
E, Iris ; Biett, an E. annulare, seu circinatum, seu centrifugum ;
and Euchs, an E. gi/ratum, an E. urticans, and an E. diffusum.
But these various names by no means answer to as many distinct
diseases ; and therefore our first object must be to determine which
of them apply merely to appearances developed in succession during
the course of one and the same disease, and which of them are
necessary to indicate cutaneous affections really different from one
another.

Now, in reference to this point, experience has taught me that the
E. pa2iulatum., E. tuberculatum, E. annulare, E. Iris, E. gyratum,
are merely forms of the same disease in different stages, the ap-
pearance varying according as the affection is undergoing develop-

^ Vide p. 146. 2 Vide p. 54.

286 ERYTHEMA EXUDATIVÜM MULTIFORME.

mentj or in a later period of its course, or subsiding. To this malady
I shall ajjply the name of Erythema multiforme.

The most striking character of this affection is its appearing on
certain special parts of the body. Thus, in every instance, it is
present on the dorsal surfaces of the hands or feet. In the more
severe cases, but only in these, it may be observed on the forearms
and legs, on the arms and thighs, and even on the trunk and face.
It is, however^ only in very exceptional instances that it affects the
regions last mentioned ; and when it is found on them it invariably
exists also on the backs of the patient's hands, where, indeed, this
cutaneous disease generally fu'st appears.

The efflorescence which I am now describing consists of flattened
papules or tubercles, of a dark blue or a brownish-red colour, and
between lentils and beans m size. Theu* number varies in dif-
ferent cases. The skin immediately surrounding them is hkewise
reddened when they fii'st make their appearance ; but this is merely
the effect of vascular injection, and lasts but a short time, subsiding,
at the latest, within twenty-four hours. When it thus disappears
this hypersemic reddening leaves behind no pigment, and the dark
red papules or tubercles then become still more plainly visible than
they were before.

In the mildest cases the papules or tubercles which (corresponding
to the El. pa^iulatum and the E. tuberculatum respectively) constitute
this affection persist only a few days. They are sometimes observed
also on the fingers, where they closely resemble chilblains (Frost-
beulen), and, when they disappear, are succeeded by a slight deposit
of pigment.

When the disease is of longer duration, the tubercles become
flattened ; their red colour spreads to the adjacent parts of the skin,
and fades from their centre. Hence, from each papule or tubercle
is developed a red ring. This change constitutes the Erythema
annulare.

Sometimes, however, the centre of such a circle is still indicated
by a smaller papule ; or, again, a second ring may develop itself
round the first, and at a slight distance from it ; so that we find
either a small ring with a papule in its centre, or two concentric
circles. These appearances characterise the Erythema Iris.

In some cases the affection comes to an end when it has under-
gone these changes. Its whole duration is then very brief; the red
colour of the circles soon subsides, and only a slight pigment deposit

ERYTHEMA EXUDATIVUM MULTIEORME. 287

is left when they have disappeared. In other cases^ however, the
rings formed from the tubercles in the way above described do not
so rapidly fade and disappear, but first spread at their margins.
Hence the different circles^ originally distinct, approach one another,
touch, and at last coalesce. In this way are produced serpentine
lines, arising from the union of the segments of several circles ; and
it is this appearance which constitutes the Eri/thema gyratuni sea
■marginatum. After a shorter or longer interval these rings at
length cease to spread; their red colour fades, and the aff'ection
terminates without giving rise to any further morbid changes,
and is followed by slight desquamation and a scanty deposit of
pigment.

It appears, then, from the description \\\\\c\\ I have given, that
the Erythema papulatum represents the lowest, and the Erythema
gyratum the highest grade, in the development of this eruption.
Hence, it will depend on the period at which the patient comes
under medical observation, whether the case shall be diagnosed as
an Erythema papulatum, or as an E. annulare, or even as an
E. gyratum. It is easy to understand how dermatologists, who
have seen such cases only at intervals (bei einer bloss ambulatorischen
Betrachtung), have supposed that they belong to different species,
whereas, when these affections are made the subject of clinical obser-
vation, the view which I have taken cannot but be adopted, namely,
that they are all identical.

The Erythema exudativum imdtiforme gives rise to very trifling
mbjective symptoms. Some patients complain of a slight burning
sensation, others of a slight itching. It is only when the papules
on the backs of the hands are nmnerous and closely approximated,
that the skin feels tense (Spannung), or thick and as if covered with
a glove (Pelzigsein) . The temperature of the surface is not, either
subjectively or objectively, increased to any extent.

Concomitant and/ebrite symptoms are to be observed only in excep-
tional cases ; in those cases, namely, in which the affection spreads over
large tracts of the surface, or even over the whole skin. No important
complications, or sequelas, occur in the train of this eruption. Its
whole duration varies between one and four weeks. I have once
seen the Erythema papulatum accompany a pneumonia, of which
the patient died. Each one of the papules was plainly visible on
the dead body, and, when they were cut through, it became evident

288 ERYTHEMA EXUDATIVUM MULTIFORME.

that they were caused by hsemorrhagic exudation (durch hämor-
rhagisches Exsudat) .

The Er>/thema papvXatum is peculiar iu the time of its occiu'rencc,
aud in its hability to relapse. This affection presents itself only
during those months, namely, April, May, October, and November,
in which erysipelatous and herpetic eruptions are likewise most
frequently observed. Moreover, its recurrence is connected with an
annual type {Typus annuus) ; for there are persons iu whom such
an erythema breaks out, during many successive years, in the course
of the same month.

In some cases there appear, simultaneously with these forms of
erythema, eruptions which are of a similar kind, excei)ting that
they are vesicular. These were, consequently, classed by AVillan
under the name of Herpes. It is, however, impossible to doubt
that the Kerpes Im and the //. circinatus arise from the same
causes as the Erythema Iris and the E. annulare, and differ only
in the fact that, in the first two affections, vesicles running an acute
course are developed, Avhich arc associated in groups, and surround
a common centre.^ All the other characters are the same in the two
groups of diseases, and the opinion long since expressed by Rayer,
that the Erythema Iris and the Herpes Iris] are mere modifications
of one afl'ection, is, doubtless, correct. There is, however, a prac-
tical advantage in retaining both these terms, because doing so
enables us, not only to adhere to the definitions of the two diseases
{Herpes and Erythema), but also to indicate at once, by the name
which we employ, which form is present in any particular case.

We are in a state of complete ignorance as to the cause of these
erythemata. They are certainly never produced by local irritation ;
and no disease is known to us (with the exception, perhaps, of
cholera),^ in the course of which they regularly present them-
selves.

' This point will be more fully discussed in the chapter upon Herpes,
- The rash which breaks out in epidemic cholera is, indeed, generally regarded
as a Roseola, and described as the Roseola cholerica. But, in my opinion, it
would be moi'c correctly termed an Erythema papiilatum. In the cholera
epidemics which have occurred in Vienna I have observed it in about one per
cent, of the cases, and chiefly in those which terminated favorably. It generally
made its appearance quite at the end of the disease, when the choleraic
symptoms had subsided, and during the secondary fever. It occupied
the backs of the hands and feet, and also the forearms and legs ; and it had
rather a bluish-red or livid colour. It generally survived the proper choleraic
symptoms, not passing into any other form of erythema (such as the E. unnu-

ERYTHEMA NODOSUM. 289

I have seen these affections chiefly in young subjects^ who were^
in other respects, perfectly healthy. They arc more common in the
male than in the female sex ; but I have never been able to discover
any predisposing cause for them in the patients themselves. These
erytliemata are often ascribed to catching cold, or to errors of diet,
or to mental emotions ; but unless the real existence of these con-
ditions can be proved, I regard such expressions as mere common-
places and shibboleths (Gemeinplätze imd Schlagworte) ; and,
rather than avail myself of them, I shall confess that the cause of
these diseases is altogether unknown to me. It is certain that they
do not owe their origin either to the imbibition of alcoholic liquors,
or to eating any particular kind of food, whether sour, sweet, or
bitter, whether of animal or of vegetable nature.

The treatment of these erytliemata must be purely expectant. All
local applications have proved useless ; and internal remedies are,
from the nature of the case, superfluous ; for, as I have stated, the
complaint terminates spontaneously without leading to any evil con-
sequences, and within four weeks at latest.

B. Erythema nodosum.

Differing from the affections last described in its form, seat, and
course, and also in the symptoms by whicli it is accompanied, the
Erythema nodosum, or Dermatitis contusiformis, must be described
as an independent malady. With most other writers, I apply these
terms to an affection consisting of tumours (Geschwülste) of a pale-
red colour, raised above the level of the skin, and either semi-
globular or oval in form. These swellings are tender on pressure,
and are observed chiefly on the lower limbs.

lare, H. iris, or U, gyratuni), but remaining as an ^, papulatum, sometimes even
for a fortnight. Indeedj patients in the hospital, convalescent from cholera
and presenting this eruption, were transferred for treatment to the department
for diseases of the skin. The affection ran the same course as in other cases,
and ended as usual in slight desquamation, and in the deposition of pigment in
small quantity. [A note from Prof. Hebra informs methat during the present
year (1S66) this rash, in a macular or papular form, has been observed in about
the same proportion of cases of cholera. — Ed.]

According to the statements of Uigler (' Die Türkei und deren Bewohner,'
Wien, 1842, ii Band, s. 44), and of Gustav von Gaal, this form of erythema
prevails endcmically in the provinces of European Turkey.

290 ERYTHEMA NODOSUM.

In some cases,, the outbreak of this form of erytliema is preceded
by slight febrile disturbance, and even by shivering. But sometimes
the attention of the patient is first directed by his senses of sight
and touch to the presence of the semi-globular protuberances.
These are generally of different sizes, the smallest being perhaps
of the size of peas, the biggest as large as a man's fist. They are,
for the most part, perfectly distinct from one another. They have
at first a pale rose-red colour, with a slight tinge of yellow.
Afterwards they become dark-red, and then livid ; and when the red
colour has faded, a yellowish coloration (Pigmentu'ung) remains for
a considerable time. These swellings, in fact, pass through the
same changes of colour which are observed in the bruises produced
by local injury; and hence the name Bermatitis contusiformis, which
lias been apphed to this att'ection by several authors.

The number of these tumours (Knollige Hervorragungen) varies
in different cases. Sometimes they are confined to the legs below
the knees, and are few in number, at least ten of them, however,
being present. Their course is then such as has been above de-
scribed. In other cases, a second or even a third eruption of these
tumours takes place, affecting each time parts previously free from
them, so that the thighs, forearms, and upper arms, the trunk, and
even the face, are, in succession, covered with them. The duration
of the disease as a whole is of course prolonged by the occurrence
of these repeated attacks ; and the sympathy of the system gene-
rally is likewise shown by the fact that paroxysms of fever, of more
or less severity, precede each fresh outbreak. Moreover, these ex-
ceptional cases of Eri/thema nodosum, in which the eruption is so
extensive, are attended by loss of appetite, depression, sleeplessness,
or, in other words, by general malaise. However, none of the more
important organs of the body are ever especially attacked ; and the
extent to which the skin is affected is surely in itself sufficient to
account for the febrile symptoms.

Whether this form of erythema is partial, or diffused over all
parts of the body, it always terminates within from two weeks to a
month, without undergoing any changes other than those which I
have mentioned. In particular, these tumours never suppurate or
break down into abscesses. So, again, itcldng is never among the
symptoms of this disease, painful sensations alone being produced
by it. Lastly, tlie redness of the individual tubercles never spreads

ERYTHEMA NüDüRJUM. 291

to the skiu around them ; a character which distinguishes the I,rij-
thema nodosum essentially from fm-uncular affections^ erysipelas, and
urticaria, as well as from the other varieties of erythema already
described.

It is very probable that, in its pathological anatomy, the Erythema
nodosum is allied to absorbent inflammation, and likewise to the
erysipelatous diseases ; and the same thing may, perhaps, be said
also of the other erythemata. Indeed, it admits of no doubt whatever,
that the morbid process concerned in some cases of Erythema no-
dosum is essentially an inflammation of the lymphatic vessels.
In fact, we see instances in which the tubercles are arranged longi-
tudinally in the coiu-se of these vessels in such a way as to present
the ordinary appearance of a lymphangioitis. However, it has not
hitherto been possible, either during life or by post-mortem exami-
nation, to furnish a complete proof that the seat of such affections
is to be sought exclusively in these structures, and therefore the
proposition that these exudative erythemata are merely lymphan-
gioitides is at present nothing more than a very probable hypo-
thesis.

The Eri/thema nodosum is observed most frequently in the female
sex ; but men likewise are sometimes affected with it. In either
sex, it occurs more commonly between the ages of fifteen and thirty
years than at any other time of life.

As I have already stated, all these forms of erythema come to an
end spontaneously within a definite period, and leave behind them
no ill effects. Moreover, they invariably terminate in recovery.
Hence it is quite unnecessary for me to enter into any details
as to their treatment, I have merely to mention, that in the
Erjjthema nodosum, and indeed in aU the erythemata, we should
avoid the use of any active local applications for the relief of the
pain caused by the cutaneous affection. Cold wet rags may be em-
ployed for this purpose; or if it is necessary to prescribe some-
thing, Goulard water may be ordered. Or, should cold be dis-
agreeable, warm fomentations may be used ; and, for this purpose,
some simple infusion, such as the infus, malva, or the infus, jacea,
may be prescribed. These applications do not annoy the patient,
and in no way disturb the natural course of the disease. Some
medical men, however, suppose that the tincture of arnica is a per-
fectly harmless remedy in the Erythema nodosum, and in similar
affections. But I woidd give a friendly warning to those who ad-

292 ERYTHEMA NODOSUM.

vocate its use ; unless, indeed, they propose to employ it homceopa-
thicaUy and in infinitesimal doses (als Hoclipotenz) . In the proportion
of a drop of the tincture to a pail of water, this substance may
certainly be applied without any risk of doing harm. But I have
in practice had abmidant occasion to observe that the tincture of
arnica, even when mucli dihited, acts most injuriously upon the skin
of some persons. I have frequently seen eczema or dermatitis
excited by the assiduous application of lotions containing this drug,
in the treatment of slight bruises or sprains.

If, in a case of Eri/ihema nodosum, the symptoms generally sug-
gest the administration of some particular internal remedy, we must
act in the same way as though the cutaneous affection did not
exist. This, in itself, requires no such treatment. But when
the patient at the same time suffers from attacks of intermittent
fever, quinine is, of course, indicated. Again, bitter remedies may
be prescribed, if the appetite is bad ; laxatives or purgatives, if the
bowels are confined; and, lastly, anodynes, if the patient cannot
sleep.

The two diseases i:)ellagra and acrodynia (the latter being a com-
plaint which prevailed in Paris in the year 1828) were described
by Alibert under the names of endemic and epidemic erythema.
And although I do not hold that these maladies are identical with
the affections just described, in their essential nature, in their coiuse,
or in most of their other characters, yet it appears to mc advis-
able to mention them iu this place, because, vi'hatever their real
nature, they must, in any case, be regarded as belonging to the
exudative erytliemata.

PELLAGRA. , 393

PELLAGRA.
By TUE LATE PROFESSOR MAYK.

{Pellis u^gra, Bisipola Lombaräa, der lombardische Aussatz, Mal
Rosso, Mal del Sole, Mal del Padrone, Cattivo Male, Male
della Vipera ; in Spanish, Mal de la Rosa.)

Tliis disease was first fully described in the middle of the last
century, by Trapoli, Odoardi, Gherardini, Strambio, and others.
It prevails endemically, but chiefly among the poorer classes of the
population, in Lombardy, Piedmont, Veuetia, and the South of
France.

The erythema observed in this complaint is only one of the symp-
toms of a general and deeply seated malady, which destroys the
organism.

The eruption appears, during spring and summer, on those parts
of the body which are exposed to the rays of the sun. Thus, it
affects the hands (and particularly the backs of the hands), the
forearms (on their extensor surfaces), the neck, and those parts of
the chest and back which are not covered by the shirt. It is chiefly in
women, in whom the countenance is more exposed to the sun, that
the rash occurs on the face ; for men generally wear straw hats
while at work, whereas women have a less suitable covering on their
heads. When the face is affected, the parts which become reddened
are the dorsum of the nose, the cheeks, and sometimes the forehead.

When not very severe, the eruption generally subsides sponta-
neously on the approach of autumn or winter, as the weather
becomes cooler. It then leads to a trifling desquamation, and leaves
behind a slight deposit of pigment. But if the patient should again
expose himself during the next summer to the bright rays of the
sun, the erythema returns with greater intensity than before.

At the same time that this cutaneous affection makes its appear-
ance, the patient suffers from muscular weakness and mental de-
pression. When at work, he soon gets tired, and is obliged to rest ;
and he becomes silent and melancholy. This condition, which often
goes on for several successive years, is termed l)y Italian authors
the first stage of pellagra.

294 PELLAGIIA.

The second stage is regarded as commenciug at the time Avhen
certain new and severe symptoms set in, or when those previously
observed undergo a marked aggravation. The fresh symptoms
which now present themselves do not concern the eraptionj but
rather indicate the progress of the internal malady. Thus, the
patient is attacked with severe headache, giddiness, cramps,
rigidity of the muscles of the neck and limbs ; and his senses and
intellectual faculties become impaired. The face acquires a look
resembling that of lunatics (Geisteskranken) ; indeed, these poor
creatures often at last fall into a state of dementia or of melan-
cholia, which last is generally of a religious kind (Melancholia reK-
giosa) . Sometimes, symptoms resembling those of delirium tremens
set in, in which the patient is irresistibly impelled to commit suicide,
and especially to drown himsehf (Hydromania) . Death occiu-s either
by marasmus, colliquative diarrhcea, or dropsy ; or, again, as a result
of the acnte inflammation of some internal organ.

The science of pathological anatomy has, as yet, contributed
nothing towards the explanation of this mysterious malady. Ozanam
states that, on post-mortem examination, he found the brain and the
thoracic organs healthy, and that the liver and spleen alone presented
morbid changes, which resembled those observed after intermittent
fever, and in rachitis and chlorosis. The most numerous details as
to the appearances observed after death are, however, given by
Labus.^ According to this writer, the arachnoid is found opaque
and thickened ; the substance of the brain and spinal cord atro-
phied and indurated ; and the cerebral ventricles dilated and filled
Avith an increased quantity of serum. He also states that the lungs
are in parts hypersemic, but the liver and intestines empty of blood,
and that the alimentary canal (especially the small intestine) is
generally observed to be contracted in a great part of its length.

Wben the erythema of pellagra has made its appearance for
several successive years, its colour becomes much darker, and the
part affected is also found to be covered with a deeply pig-
mented brown or black epidermis. The skin also feels hot to the
touch ; and the patient now complains of a burning pain, and, in some
cases, of occasional sensations of itching. When these darkly pig-
mented patches of cuticle have become detached in the form of
brownish black, thick, leathery masses, the siu*face of the skin be-

* Dr. Pietro Labus, 'La Pellagra investigata sopro quasi ducento Cadaveri
di Pellagrosi,' &c., Milano, 1847.

PELLAGRA. 295

neath is seen to be thickened over a certain well-defined area^ and
to present a deep-red line. Its colour is now generally permanent,
no longer disappearing beneath the pressure of the finger, as it did
when the disease first began.

Thus the natural appearance of the skin becomes altered and de-
formed; and it was this which gave origin to the name Elephantiasis
Italica, proposed by Dr. Mason Good. It constitutes what is termed
the third stage of pellagra.

According to Strambio and Ozanam, however, who are trust-
worthy authorities, certain cases of this disease occur in which the
erythema is wanting, the only symptoms being such as indicate an
afiection of the brain and spinal cord.

The course of pellagra is protracted ; this disease generally
lasts from three to five years, and may even, though less frequently,
have a duration of eight or twelve years. A perfect recovery fi'om
it is very rare ; persons who have been attacked generally remain
stupid and incapacitated for every kind of w^ork. Fewer men than
women suffer from pellagra, and children are still less frequently
affected by it. The period betW' een thirty and fifty years of age is
that at which this malady is most common.

The statements of Ozanam and other authors, that this disease,
though not contagious, is hereditary, may easily be explained by the
consideration that the injurious influences which cause it generally
act upon all the members of a family at the same time, or at any rate
upon several of them, and that, in consequence, parents and their
children are often attacked together.

Writers upon pellagra ascribe this disease to different causes.
Some think that it is due to the wretched circumstances of those
who most frequently suffer from it. Indeed, they are, as a rule,
poor country people who are constantly exposed to the sun's rays,
and have to do the hardest labour on scanty food, and in a hot, dry
atmosphere. Inhabitants of towns, and persons in good circum-
stances, are never affected with pellagra. But there are other
countries, in the same latitudes, in which this disease is not
met with, although the inhabitants of these countries hve under
exactly similar conditions. Hence it seems extremely hkely that
other causes are required for the generation of pellagra, in addition
to the injurious external influences already referred to.

The opinion that this complaint is caused by living upon maize
(poUenta) is the one which is most generally mamtained by Itahan

296 PELLAGRA.

physicians aud medical writers. But in tlie South of Eraiice, aud
in Tui'key, the labouring classes are supported by the same kind of
food, and yet pellagra is not endemic in these countries.^

According to Ballardini- and other authors, liowever, the occur-
rence of this disease is due to the fact that, particularly in cold and
wet seasons, the unripe grain of the Zea Mais, being in a morbid
condition, becomes affected with a parasitic fungus, the Sporisomim
Maidis. This condition of the maize is very common in the northern
parts of Italy ; and the blighted grain is eaten by the poorer country
people, who get no animal and no other vegetable food. That this is
the cause of pellagra is rendered probable by the fact that those
who are better off, and take other kinds of nourishment besides the
maize, escape the disease. Indeed, some have maintained that, even
when pellagra has already commenced, it is possible to check its
further progress by feeding the patient on a mixed diet.^

Pellagra prevails endemically in Italy to so great an extent that,
as long ago as 1784, Strambio declared a twentieth part of the
population to be affected with it. It appears, on statistical evidence,
that in 1 830 there were in North Italy (Oberitalieu) alone, 20,000
cases of this disease, the number of inhabitants being a million and
a half (Ballardini) .

Treatment. — The erythema which accompanies pellagra always
disappears spontaneously, when the part is no longer exposed to the
injurious influence of the sun's rays. Even if the patient should
be unable to find a different occupation, or to live in some other
district, the further development of this cutaneous affection may be
altogether prevented by protecting those parts of the skin which
have hitherto been uncovered.

In the hope of curing the general symptoms of this disease,

^ Pellagra does, however, prevail to a very considerable extent in the part
of Prance near the Pyrenees ; and, indeed, in some other districts also.
Dr. Costallat, of Bigorre, is one of the most energetic supporters of Ballardiui's
views. — [Ed.]

- 'Annali Universali (Omodei),' April, 1845.

' I have myself seen a large number of cases of pellagra. The disease, in its
general characters, undoubtedly bears the closest resemblance to other affections
(lutoxicationen) produced by the ingestion of corn in a blighted (verdorben)
state. The action is, indeed, slower in the case of pellagra, aud the course of
the complaint is more protracted ; but the system is not the less deeply affected
by it. One is involuntarily reminded of ergotism (Raphania, Kriebelkrankheit).
— [Hebra.]

ACRODYNIA. 297

the antiphlogistic method of treatment is^ unhappily, still carried
to the furthest possible extent. Each time the patient becomes
at all excited, he is forthwith bled. Indeed, one finds, in the
Italian hospitals, not a few luckless patients, affected with pellagra,
who, in the course of a single year, have undergone vensesec-
tion as many as a hundred times, and yet have not died. Fortu-
nately for these poor creatures, this procedure is gradually being
more and more completely given up, and physicians are contenting
themselves with a more rational line of practice.

For, by giving pellagrous patients, instead of the bad pollenta, a good
mixed diet, and particularly meat and milk, and by keeping them in
well-administered and well-managed hospitals, these unhappy beings
may be restored to perfect health, without any other treatment what-
ever. OfcImary^tepTdr^aths, but especially salt-water baths, are
praised by some writers. "Washing the surface of the part with
milk, whey, or infusion of mallow — or, on the other hand, with
lime-water, or a dilute solution of sulphate of iron — is recom-
mended as a cui-e for the eruption. But it is probable that this end
w^ould be attained quite as quickly, without any such applications,
under the influence of the above-mentioned favorable conditions.

AcßODYNIA.

[Erythema epidemicwii , seu Acrodi/nia.)

I think it necessary, for the sake of completeness, to mention this
disease, which prevailed epidemically in Paris in 1828 (as we learn
from the description of it given by Ahbert), and was also observed,
according to Hirsch, in the years 1829 ^^^ 1830.

The symptoms of this malady were the following : — The hands
and feet of the patient became reddened and sAvollen ; he complained
of sensations of formication or pricking, or even of throbbing pains,
such as are produced by severe bm-ns. In some individuals, the
reddened patches presented no further changes, except that they
underwent desquamation, and became the seat of a deposit of pig-
ment ; but in others there arose vesicles and bullae, which afterwards
burst and allowed their contents to escape. In these cases, again,
as in the others, desquamation occurred; and, in the course of
it, large and very thick pieces of cuticle often peeled off. In many
instances, other parts of the skin, besides those already mentioned.

298 ACRODYNIA.

became affected with similar red maculae. Such patches, for example,
appeared on the thighs, legs, and forearms ; and, in these regions,
some of them had a purple or violet colour.

But what appeared the most extraordinary symptom of acrodynia,
to those who observed this epidemic of the disease, was the black
colour, as of soot, presented by the surface of the abdomen, chest,
and axillse, so that the skin of the patient resembled that of a
chimney-sweep. In some persons, however, the surface did not dis-
play this appearance, but rather looked as if covered with cobwebs.
Moreover, the epidermis, in other cases, became dry, hard, and lea-
thery (schwielig entartet) , and rubbed off in the same way as in
those who have been exposed for some time to the heat of the sun.

In addition to these symptoms, the patients were afterwards attacked
with numbness of the lower limbs, so that, in walking, they could
not feel when their feet touched the ground, and, therefore, were
obliged to be assisted by others. At the same time, their hands and
feet became affected with involuntary trembling movements ; and the
pain in them was often so severe as to be compared to that caused
by tearing out the nails with a pair of forceps. Vomiting, diarrhoea,
colic, dysuria, suffocative and spasmodic attacks of coughing, and
ophthalmife, were also among the symptoms observed iji these
cases, and often put an end to the life of the patient.

In the opinions of the physicians of the day, such as Chomel,
Recamier, Chardon, and others, this affection bore a close resem-
blance to pellagra and to raphania, and, like these diseases, was
very probably caused by the employment of grain in a damaged
condition.

As I propose in this place not to write a complete description of
acrodynia, but merely to point out the position which it occupies in
my system, and to draw the reader^s attention to this very interesting
disease, I shall say no more concerning it, and refer those who
desire more detailed information to the work of Dr. Hirsch,^ of Danzig.
This book is an appendix to the *■ Handbuch der speciellen Patho-
logie und Therapie,' of which the German edition of the present
volume forms a part.

' 'Handbuch der historisch-geographischen Pathologie,' 8vo, 1859.

ROSEOLA. 299

II. Roseola.

[Rosalia, Biiheola, RötJieln, Rütteln, Wieieh, Feuermasern, der
rothe Hund.)

Under tlie name of Roseola, "Willan describes a group of cuta-
neous affections, in which, besides the R. infantilis, R. variolosa, and
R. vaccina (which I place among the Hypersemise), he includes the
R. astiva, R. autumnalis, R. anmilata, R. miliaris, wAR. typhosa.
The example of this writer has been followed by most of his con-
temporaries and successors, not only in England, but also in Prance
and Germany, Indeed, in works on diseases of the skin, roseola
occupies a position of some importance, appearing by the side of
morbilli and scarlatina as a third exanthem. Unbiassed observa-
tion, however, shows that such cases of roseola are either forms
of measles, of slight intensity, in which the catarrhal affection is
nearly or altogether wanting, or instances of mild and imperfectly
developed scarlatina ; or, on the other hand, that they might just as
well be included under the head of Urticaria. It is, in fact, quite
unnecessary to describe by the name of roseola or rubeola (Rotheln),
a special exanthematic eruption. Indeed, this view has already been
maintained by many physicians in different countries; so that, in
putting it forward, I am asserting nothing absolutely new, but am
rather joining the side of certain other writers, who deny the ex-
istence of a Roseola suhstantiva .

It may, however, be well to criticise in detail the forms of roseola
admitted by Willan. Now, in the first place, experience does not
warrant the recognition of a R. cestiva, and a R. auhimnaUs. Tor,
to be justified in admitting these species, we ought to find one par-
ticular rash appearing principally during summer, and another more
often in autumn. Moreover, these affections ought to be distin-
guished not only by occurring at different seasons of the year, but
also, and mainly, by peculiarities in their symptoms. As for the
differences in the appearance of these eruptions, it would seem, from
Willan^s plates,^ that the R. cestiva consists of maculfe grouped in a
serpentine form, while the R. autumnalis has rather a discoid cha-

' Op. cit., plate xxvi.

300 ROSEOLA.

racter. So far as I kuow^ however^ these peculiarities have been
recognised by no other dermatologist. Again^ Willan states that
the R. (estiva, " at first red^ soon assumes a deep roseate hue ;"
while the colour of the R. aiitumualis " is very dark, so that, at a
distance, the skin appears as if stained with the juice of black
cherries or mulberries." This, liowever, is evidently erroneous ;
unless, indeed, it refers to some cutaneous disease which is extinct, and
at the present day no longer met with. As for the R. anmdata, it
would be difficult to distinguish between it and the Eri/thema annu-
lare, and the se^aaration of these affections is clearly inadmissible.

Hence, I believe myself to be facilitating the study of dermatology,
and moreover to be on the side of truth, in denying absolutely the
existence of any one of these three forms of roseola ; and I hold
exactly the same opinion with regard to the R. miliaris, of which I
shall say all that is necessary, when describing the forms of miliaria.

It is otherwise with the R. tijphosa, an aifection which is men-
tioned by Willan, but only cursorily and at the end of his account
of the roseolce. It is, however, evident from the description which
he gives of this rash, that Willan was accurately acquainted with
its appearance. He speaks of it in the following words :^ — ^^In
the typhus or contagious nervous fever, an efflorescence also takes
place occasionally, resembling in its distribution the specimen
of roseola exhibited in plate xxvi, fig. 1, but of a darker hue.
I have observed such a rash on the fom-teenth day, in a case of fever,
which terminated on the seventeenth day. In other cases it precedes
the formation of purple spots or vibices ; and in others it is seen
early in the disease, but remains only for a short time, without any
material consequences." There is a perfect agreement between this
description of Wülan^s and the results of the observations which I
have myself had an opportunity of making. I also recognise, in
this form of roseola, a symptomatic eruption or skin afi'ection accom-
panying typhus fever,^ and taking the form of dark-red maculse or

1 Op. cit., p. 451.

' In auswer to my inquiry, to which form of fever the remarks in the text
are intended to apply, Prof. |Hebra states that he means the macular rash,
which occurs early in the "typhus exauthematicus," and which is sometimes
seen in the course of " ileo-typhus" (enteric fever). In a previous note, how-
ever, he told me that he generally uses tiie term "typhus" to indicate the
disease " in which the spleen is enlarged, and the Peyerian glands swollen."
This form of fever (enteric fever) is the most common in Vienna. — [Ed.]

URTICARIA. 301

circles. It is seated principally on the limbs^ and makes its appear-
ance at different periods of the disease; sometimes quite at its
commencement, in other cases only towards its end. It does not in
any way modify the course of the fever.

In some epidemics this eruption is of unusually frequent occur-
rence ; but no certain conclusion can be drawn from this fact as to
the benign or malignant character of the prevailing malady. The
Roseola tijpliosa is followed by a slight desquamation, and leaves
behind it a deposit of pigment ; but it is not liable to any other
changes. The reason for the appearance of this rash in cases of
typhus is as yet unknown. But the fact that no change in the
course of the fever has been observed to be produced by either its
presence or its disappearance, renders it quite unnecessary to have
recourse to any therapeutical interference, so far as the roseola is
concerned.

III. Urticaria.

{Nessehucld, Nesselfieber, Nesselausschlag, NeUlerash, Fehis
urticata, Essera, Porcellanfnesel, Cnidosis, WiehelsucJit.)

Urticaria is characterised by the development of wheals (Quad-
deln, Cnesmi), of a white or red colour, and is accompanied by
sensations of stinging or itching, like those produced by the sting-
ing-nettle (urtica). This rash appears suddenly, is of very brief
duration, and is followed by no desquamation.

The English, Latin, and German names for it have reference to
the effects produced on the skin by contact with the urtica. The
Arabian physicians and those of the middle ages termed the affec-
tion Essera (Porcellanfriesel). It has also been divided into two
diseases, the one acute, the other chronic; the former being
called the Febris urticata (Nesselfieber), and the latter receiving the
name of Cnidosis, Cnesmus (Nesselausschlag und Wiebelsucht).

This eruption was known even to Celsus, but was then confounded
with the vesicular affection (sudamina) caused by sweating. The
Arabians described it under the name of Essera, as the typical
(ausgeprägt) form of disease, in which wheals are present. Syden-
ham placed it among the erysipelatous inflammations (erysipelatoses),
and his example was followed by Euchs and the natural-historical
school. Nettlerash has often been confounded with scarlatina or

302 URTICARIA.

v.itü miliaria (Friesel) : indeed^ this is evident fi'oin the existence of
sucli expressions as Scharlach-Nesselfieber and Porcellanfriesel.

A detailed account of the literature of this subject may be found
in special treatises on diseases of the skin, and particularly in that
of J. Frank. More recent works merely contain observations of
individual cases. [Cetta, Yicent., 'Diss, de Urt./ Ticin. reg., 1842.
Veiten, '^Ueber die Natur der Quaddeln," 'Med. Correspondenz-
blatt Rhein- und Westphähscher Aerzte/ Aug., 1843.)

Urticaria sometimes makes its appearance without any prodromi
having existed, and without any disorder of the general health, the
patient's attention being drawn to the presence of the rash only by
the itching which he experiences, and by the reddened state of his
skin. In other cases, liowever, this eruption is preceded by feelings
of anxiety and malaise ; or it may accompany fevers attended with
gastric or catarrhal symptoms ; or, lastly, it may be associated with
intermittent fever (J. Frank).

The rash may either affect at once the whole cutaneous surface, or
it may be partial, being confined, for example, to the face or limbs.
Its invasion is sometimes sudden ; in other cases, the eruption is
developed successively on different parts of the body, at more or less
distinct intervals. After having been annoyed by sensations of
tension or itching, by which he was involuntarily compelled to
scratch himself, the patient finds that the skin has become hot and
red, and is covered with wheals, which are at first detected more
readily by touch than by sight.

These wheals may be either paler or redder than the healthy skin.
Those which are white are often surrounded by a very small red
border (Halo). Severe itching and stinging are present, the inten-
sity of these sensations being proportionate to the extent of the
efflorescence.

Urticaria is remarkably fugitive and erratic. The wheals often
vanish suddenly from one part of the cutaneous surface, only to
reappear at some other point. Or, again, they pass off altogether,
and then, after a longer or shorter interval, break out a second time.
Under the action of artificial warmth, or when fever is present,
this rash becomes developed to a greater extent, and gives rise to
more irritation.

Nettlerash often makes its appearance in the course of other
febrile or non-febrile complaints, without our being able in every
case to prove that it is a regular part of the symptoms which cha-

SYMPTOMS. 303

racterise the disease (eine Theilersclieiuuiig des ganzen Kraukheits-
bildes darstellt). This fact, of course, enables all those writers who
ascribe every cutaneous affection to some internal malady, to assert,
when the rash suddenly disappears, and the other disease at the
same time becomes aggravated, that metastatic deposits of the
materia peccans in some internal organ have taken place. Indeed,
some observers have been led, by their fondness for recognising
metastatic processes, to ascribe to the subsidence of the urticaria
the occurrence of ophthalmia, oedema, or even inflammation of the
brain.

The signs that this efflorescence is beginning to decline are, the
fading of the inflammatory areola, the cessation of the painful
itching, and the circumstance that the wheals feel softer than before.
The spots at which wheals were present may be distinguished, for a
very short time after the disappearance of the rash, by having, for the
most part, a pale yellow colour, or, at any rate, by being of a colom*
different from that of healthy skin.

Urticaria is not followed by desquamation. At spots which have
been injured by the repeated rubbing and scratching, there appear
either white linear excoriations, due to the tearing apart of the
dijfferent layers of the cuticle, or (should the scratching have been
still more severe) small black crusts, produced by the drying up of
blood which has escaped from the vessels of the cutis.

This complaint may be either altogether unattended with fever, or
associated with febrile symptoms. In the first case, no other affec-
tion whatever is sometimes to be discovered ; but, in other instances,
signs of gastric disorder are present, such as a furred state of the
tongue, loss of appetite, nausea, vomiting, and diarrhoea. On the
other hand, in cases accompanied by fever, the symptoms are quite
as variable as in any other febrile complaint. Indeed, this diflers from
the preceding form of urticaria only in the presence of acceleration
of the ' pulse, and increased heat of skin, and also of languor, de-
pression, and muscular weakness.

Each individual wheal remains visible only for a very brief period ;
and when several of them are formed simultaneously, they all
subside within a short space of time. In other words, the course of
any one eruption of nettlerash is invariably acute. But it often
happens that fresh Avheals arise in succession, either every day, or at
longer or shorter intervals, and, at any I'ate, before the disappearance

304 URTICARIA.

of those previously developed ; and thus, by the coustaut repeti-
tion of these attacks, there is produced a chronic tirticcma.

Hence, the duration of this disease must be set down as extremely
variable. The eruption in many cases remains visible only for some
hours [Urticaria ej^hemera), or at most persists during a few days
[Urticaria acuta seu evanicla). But, in other instances, after having
completely subsided, it recui's at the end of a longer or shorter time
( Urticaria recidiva) ; or it may linger for many months, or even
years, never vanishing altogether, but leaving each part in turn, only
to reappear at some other i^])ot] [Urticaria perstans, seu Urticatio,
Nesselsucht).

Urticaria is not, in itself, a disease of any great importance, nor
does it ever terminate fatally. Hence, the only cases in which it
could be necessary to give an unfavorable prognosis, would be those
in which this eruption should accompany some other dangerous
malady, by which, in fact, and not by the urticaria, the death of
the patient would be caused.

The most transient forms of nettlerash are those which are
attended by slight fever, and are produced suddenly by some cause
which is in operation only for a short time ; whereas the proba-
bility that the course of this affection will be protracted increases
in a direct ratio with the size of the wheals, with the frequency of
their migrations to fresh parts of the cutaneous surface, and with the
absence of febrile disturbance when new outbreaks of the eruption
occur. That form of urticaria which is merely a complication of
some other complaint does not in any way increase the severity of
the primary disease. Hence the prognosis of this is not at all modi-
fied by the presence of the efflorescence on the skin.

Urticaria may be developed on any part of the cutaneous sm-face ;
but it presents certain peculiarities according to the region affected
by it. When it occui*s on the face, it generally produces an cede-
matous swelling, especially of the eyelids and lips; the wheals,
however, are less distinct than usual, and the rash, for the most part,
assumes the character of an Urticaria rubra, and consists of red
lines and strise. The neck is comparatively rarely the seat of this
eruption, which is, however, more commonly seen on the chest and
back, where, as on the face, it often takes the form of striae, and,
sometimes, of peculiar wavy lines. On the limbs it is observed less
frequently than on the trunk. When nettlerash affects the neighbour-
hood of a joint, the skin over the articulation becomes swollen and

COMBINATIONS, 305

ccdematous. If the hands and feet are attacked by it, the })atieut
often complains merely that they feel as if covered by some ^voollen
substance (klagt über ein Gefühl von Pelzigsein), and no particular
change in the appearance of the skin of these parts is to be detected.
In some cases, hoAvever, the fingers and toes become so swollen,
that their movements are interfered with.

Urticaria may be combmed -with many other cutaneous affections,
both acute and chronic. Thus we often observe wheals scattered
more or less abundantly over the surface of the skin in cases of
morbilli, and of the milder and more transitory varieties of scarla-
tina. Again, wheals frequently appear, as a result of scratching, in
those cutaneous diseases which produce great irritation, such as
lichen, scabies, eczema, and prurigo. But the following combina-
tions of urticaria with other affections are of greater importance, and
may even sometimes give rise to difficulties in diagnosis.

(i) With Ei'i/thema. [Eri/thema tirticans.) — In these cases the
intervals between the wheals are covered by an erythematous rash.
This likewise spreads to other parts of the cutaneous surface ; and
at these spots wheals also are subsequently formed. The erythema,
however, is for the most part artificial, being caused by the patient
scratching himself. Hence this affection differs very little from
ordinary urticaria.

(2) With Miliaria, Herpes, or Fenipldfjus. ( Urticaria miliaris,
vesiciilarls ^. pldi/dcenodes, et bullosa.) — In these affections the
vesicles or bullaj develope themselves chiefly upon the surface of
the wheals, and not so frequently upon the surrounding areohe.
Such an eruption bears at first sight a considerable resemblance to a
herpes, a pemphigus, or an erysipelas buUosum.

{3) With the papular form of follicular inflammation. {Urticaria
pajmlosa. Lichen urticatus of Willan.) — In this affection the wheals
are of a pale-red colour, and are at first not bigger than hempsceds ;
but they afterw^ards reach the ordinary size, and then again subside
into their original form. Finally they disappear, leaving deposits of
pigment behind them.

(4) AYith Prurigo. — This is observed chiefly in children; in
whom, according to my experience, the cutaneous affection which
afterwards presents the characters of prurigo begins with the forma-
tion of wheals exactly similar to those of urticaria. It is only at a
later period of the complaint that the pruriginous papules make
their appearance.

306 URTICARIA.

In tlie great majority of cases whicli come under our observation,
urticaria is idiopathic. But it not unfrequently appears as a con-
comitant aftectiou in the course of febrile complaints ; under sucli
circumstances, it is to be regarded as merely symptomatic, and not
at all as indicating a crisis in the primary disease. Besides accom-
panying catarrhal aflfections of the respiratory organs and of the
chylopoietic viscera, urticaria is also observed in typhoid diseases
(bei Typhen), and in tuberculous and rheumatic complaints.

Moreover, it has been asserted that it may occur in combination
with ague {Febris intermittens urticata of J. Frank) .^ The rash is
said to appear at the commencement of the hot stage, and to subside
when the fever passes off, without leaving behind any trace of its
presence. I have never had an opportunity of seeing urticaria as a
complication of intermittent fever. Indeed, I an) disposed to infer,
from the description given by J. Prank, that in the epidemics to
which he refers (and which are said to have occurred at Pavia in
1794, and at Willna in ]\Iarch and April, 1812) the eruption was
not an urticaria, but a scarlatina j^artialis.

Diagnosis. — In the description of urticaria, I have stated that
this cutaneous disease is characterised by the development of wheals
(or of papules whicli subsequently become wheals), by the presence
of itching, by the short duration of the individual wlieals, and by
fever being, as a rule, absent. These symptoms are so conclusive as
to the nature of the eruption, that, except in a very few instances,
it seems unnecessary to lay down the differential diagnosis between
urticaria and other skin affections.

1 . In the first place, this rash is distinguished from tho?e described
as the Erythema pajpulatum, E. ttiberculatum, E. nodosum, E. annu-
lare, and E. Iris, by the fact that they occupy certain special parts of
the cutaneous surface. j\Ioreüver, itching is absent in these com-
plaints, but present in urticaria.

2. Scarlatina and morbilli difler from it in their typical course,
in being accompanied by affections of the throat or air-passages, and in
the regularity with which the rash is distribated over the skin in these
diseases. Por the eruption of urticaria is observed, in most instances,
on parts only of the cutaneous surface j and concomitant symptoms
are either altogether wanting in this disease, or, if present, are of an
entirely different kind from those whicli exist iu-the exanthemata.

^ J. Frank, ' Die Hautkrankheiten/ Leipzig, 1843, Band i, p. 155.

ETIOLOGY. 307

3. Urticaria requires to be distinguished from erysipelas chiefly
when the face is the part affected. The principal differences are, that
in the former disease the redness is less intense, but that the
serous infiltration is greater, and consequently the swelling more
doughy, in urticaria than in erysipelas.

Morbid anatonii/. — Having already ^ expressed my views in refe-
rence to the nature of wheals, I have only to repeat that they arise
from an infiltration of serum into the superficial part of the papillary
layer of the corium and between the layers of the epidermis. The
red colour which they present in some cases {Urticaria rubra) is
due to the existence, in addition, of an hypereemic state of the
vessels of the papillae ; whereas, in the Urticaria alba, the hypersemia
is limited to the periphery of the wheals, and so produces the
red areola ; those parts of the skin which are actually the seat of the
wheals being rather ansem.ic than hypersemic in this form of the
affection.

No valid objection to the view which I have taken of the nature
of this eruption can be drawn from the sudden way in which it
appears and disappears. For exudations are formed with as great
rapidity in affections of other organs, (for example, in the case of
the eye) ; and in these instances the effused matters are reabsorbed
hito the blood no less quickly, as soon as the obstruction to the
circulation is removed. 2

Etiology. — Urticaria is either produced by the direct action of
external irritants upon the skin, or by the operation of internal
causes.

Among the external agents which generate it are the stinging-
nettle {urtica), and the stings of certain insects (such as bugs, gnats,
the Culex pipiens, the caterpillar of the Gasterqpac^aprocessionea, &c.).
The name Urticaria traumatica is applied to it when produced in this
way. In the centre of the wheals may be observed a point of a

' Fide p. II,

- Veiten does not regard wheals as arising from an exudative process, but
ascribes them to a spasmodic coutractiou of the surrounding part of the corium.
Up to the present time, liowever, the only muscular fibres which have been
found in the skin are those placed perpendicularly to the surface ; and, until
circular fibres shall have been discovered in the substance of the cutis, tiie view
adopted by Velteu will remain less probable than that which I have given.

308 URTICARIA.

darker colour, Avhich is the seat of the puncture. In the case of the
iiettlcj the alfectiou seems to be caused by the action of sulpho-
cyanogeu (Cyauschwefel), Avhicli escapes from the glands on the
surface of the leaf as soon as their points are broken off. When
arising from the stings of insects, it appears to be caused either by
their contiuued sucking (durch das anhaltende Saugen), or by their
boring through the tissues of the skin i (durch das Eingi'aben) ; or,
in some cases, by the introduction of formic acid.

I have already remarked that, in persons whose skin is very sen-
sitive, urticaria may be simply the effect of constantly ii-ritating the
cutaneous surface by scratching. This form of it is the so-called Urti-
caria subcutanea. It is observed especially in patients who are at the
same time affected with some other eruption attended with itching,
such as eczema or prurigo ; and it likewise often follows the applica-
tion to the skin of resinous substances, turpentine, or the ung. tcre-
binthinse [un^. digestivwa).

The internal caused of urticaria include the following :

1. Intense and sudden mental emotions, such as terror and
anger (J. Frank).

2. The ingestion of certain kinds of food, drink, or medicine.
^J^he articles of diet which most commonly give rise to nettle-
rash are, cray-fish, lobsters, oysters, fish, pork, sausages, straw-
berries and currants, &c. Ajnong medicines may be mentioned the
bals. copaibse, turpentine, valerian, the semina cinna3, the ol. anisi,
and various mineral waters (J. Trank). This effect, however, is in
])art due to the idiosyncrasy of the patient ; for whereas most persons
can take any quantity of these kinds of food or medicine Avithout ill
effects, others are attacked with the eruption after having merely

1 Of this kind is tlie complaint described by Jalm (' Jena'sclie Annaleu fiii-
Physiologie und Medicin,' Bd. i, hft. i), under the name of Slachelbeerkranlclieit
(gooseberry-disease). It affected children or grown-up persons who were
engaged in gathering gooseberries, or who had often been, for some time, close
to gooseberry-bushes. These individuals were attacked by severe itching, and
soon afterwards by an erythematous reddening of the skin, attended witii the
formation of papules. This eruption did not subside until the patients had, for
some days, avoided the neighbourhood of gooseberry-bushes. Dr. Emmerich
discovered a species of mite — the Leptus autumnalis — within the yellow points.

Similar eruptions are observed, especially during spring and summer, in
•women and children who, while in gardens, are touched by caterpillars or other
insects, such as the little scarlet Thromhydium Holosericewm. This form of
urticaria looks, at a distance, very like measles, particularly wlieu it is seated
on the face.

ETIOLOGY. 309

tasted tliem. Dr. Thomson asserts that urticaria may be caused, in
a ]iersou liable to it, by partakiug of any dish to which he is un-
accustomed ; and, in support of this opinion. Dr. Thomson appeals
to experiments made by himself for the purpose of testing its
truth.

3. Irritation of the alimentary canal by intestinal worms^ espe-
cially the Oxfjuns vermicidaris, the Trichocephahis dispar, and the
Tania solium.

4. Certain physiological changes (such as menstruation and preg-
nancy) in the sexual functions of women ; various pathological con-
ditions of the generative organs, including tumours of the uterus ;
and, lastly, those manifold disorders of the genital system (in der
Genitalsphäre) which are grouped together under the name of
Hysteria, and in which we are often unable to detect any local or-
ganic disease, either dm-ing life or after death. It is now some
years since I ^ showed that certain cutaneous diseases (among which I
mentioned urticaria) are frequently thus associated with some
pathological change in the female genital organs ; and this observa-
tion has been quite recently confirmed by Scanzoni.

It has not yet been ascertained whether the morbid change in
urticaria — the infiltration of the skin — is due to some nervous influ-
ence, or to an alteration in the composition of the blood (eine besondere
Blutmischung). But the favorable course taken by this eruption,
its being accompanied by no disease of any internal organ, the
absence of sequelae, the rapidity with which the complaint spreads,
and its yet ha^dng no tendency to lead to the formation of abscesses,
— all these facts are opposed to the latter supposition. We are en-
tirely ignorant of the causes of that form of urticaria which appears
in the course of certain diseases, such as intermittent fever and
acute rheumatism.

It has been supposed that among the conditions which predispose
to urticaria are certain states of the weather, particular seasons of
the year (and, especially, the periods of transition from winter to
spring and from autumn to whiter), changes in the electrical tension
of the air (J. Frank, Tuchs), and, lastly, the fact that the person is of
a certain age. But, accordmg to observations made here, these cir-

^ " Ueber das Verhältniss einzelner Hautkrankheiten zu Vorgängen in den
inneren Sexualorganen des AVeibes," von Hebra ; ' Wochenblatt der Ztsclirft,
d. Ges. d. Aerzle,' N. 40, 1855.

310 URTICARIA.

cumstances do not possess the influence which has hitherto been
ascribed to them. It is^ however, a fact that urticaria is more
common when erysipelas is prevalent than at other times.

This cutaneous disease is not communicable from one individual
to another. Prof, Mayr performed inoculations with blood obtained
by pricking the wheals, but these experiments altogether failed to
transmit the urticaria.

Treatment. — The indications for tlie treatment of tliis affection
are, firstly, to take away its cause; secondly, to remove the infiltra-
tion of the skin ; and, thirdly, to put a stop to the itching, or at
least to relieve it.

In the acute form of urticaria, the cause has generally ceased to
be in action before the patient comes under treatment. An emetic
or purgative should be given in any case in which the patient,
having partaken of some unaccustomed kind of food, still complains
of nausea. Generally speakmg, however, it will be sufficient to
direct that no food of any kind shall be taken, and to adopt an ex-
pectant mode of procedure. Medicines which bring out the erup-
tion are objectionable.

The cause of the recurrent variety of this disease is often easily
detected and got rid of. Thus, any particular kind of food Avhich
gives rise to it must be henceforth avoided. But when urticaria
is the effect of pregnancy, amenorrhoea, or hysteria, it may often be
difficult, or even impossible, to remove its cause. Again, we must
not forget that this rash may be due to the irritation produced by
animal parasites ; and its repeated occurrence ought always to suggest
the possibility of their presence. It is also well to remember that
bugs and gnats are not found only among the poor, but sometimes
attack even respectable people.

As we are, for the most part, ignorant of the causes of chronic
urticaria, our treatment of it is generally limited to the use of agents
which relieve the itching and tend to remove the unpleasant sensa-
ions experienced by the patient. With this object, we should keep
the patient cool, directing him to wear thin clothes, or to be hghtly
covered in bed. He should sponge the skin with cold water ; or if the
eruption is confined to certain parts of the body, cold lotions may be
prescribed. Douche baths, again, may be ordered ; or the patient may
be told to bathe in a river, or in the sea. However, the chronic
variety of urticaria often resists all these measures, and will not

TREATjMENT. 311

subside until the person affected with it has changed his residence
and altered his mode of life.

When any febrile disease gives rise to or is accompanied by this
rash, the only modification in the treatment of the case, rendered
necessary by the presence of the urticaria, is the avoidance of all
heating and diaphoretic medicines.

Some have advised that the whole body should be immersed in
baths to which common salt, bicarbonate of soda, or carbonate of
potass has been added. This, however, is quite useless. Again,
sponging the surface with dilute vinegar, or a solution of citric
acid, has been recommended for the removal, or at least the
relief, of the itching. It must be repeated as often as this painful
sensation returns, but its effects very rarely answer to its reputa-
tion. Duchesne-Duparc^ recommends the internal administration
of the tincture of aconite, as a specific remedy for the itch-
ing. He gives a daily dose, " varying from a few drops to several
grammes, according to the age and temperament of the patient."
However, I have never seen any striking effects produced by this
medicine, which, hke arsenic and every other internal remedy, has
always proved unsuccessful in the treatment of the chronic, recur-
rent form of urticaria.

^ ' Traite pratique des Dermatoses,' Paris, 1859, p. 33. M. Duchesne-Duparc
states that he employs an alcoholic tincture made with the fresh leaves of
the aconite; but he does not mention the strength of his preparation, for
which several very different formulce are given by Jourdau ('Pharm. Univers.,'
126). It is hardly necessary to say that the tincture of the British Pharma-
copoeia should not be given in a dose of " rtlusieurs grammes" — [Ed.]

CHAPTER Xin.

ON THE DERMATITIDES PROPER.»

(CLASS IV.— ACUTE, NON-CONTAGIOUS, EXUDATIVE

DERMATOSES.)

A. Dermatitis Idiopathica."

I. Dermatitis Traumatica.

Under this name I include all those inflammatory cutaneous
affections, caused by agents of which the injurious effects are me-
clianical. These effects include lacerations of the tissues of the
skin, followed by a hypersemic condition of the cutis, and by the
pouring out of exudation into the substance of the integument.
To this form of dermatitis, then, belong the bruises (Beulen) and
inflammatory swellings (with the other conditions into which these
afterwards ])ass) produced by forcible pressure on the surface of the
body, or by a severe blow or fall, or by a violent push or crush-
ing injury. It is, however, scarcely possible to give a general
description of these morbid conditions of the skin, for they present
every variety of form, extent, and severity, according to the degree
of force employed and the vulnerabiHty (Vulnerabilität) of the indi-
vidual. I shall, therefore, content myself with having pointed out
the proper place in my system for these forms of dermatitis.

' Vide p. 147, supra.

- It is obvious that this epithet is here (and also in other parts of this work)
employed in a sense different from that in which it is generally used in this
country. We speak of a complaint {e.g. tetanus or peritonitis) as being idio-
patkic, when it is not produced by any evident exciting cause, such as an in-
jury. Prof. Hebra calls those diseases idiopathic which are not symptomatic,
that is, not mere symptoms of some other general malady, but substantive and
independent affections. — [Ed.]

PERMATITIS CALORICA, 313

2. Dermatitis venenata.

When treating of the idiopathic forms of the hypersemic erythe-
mata^^ I had occasion to speak of an Eri/thema ab acribus, seu venena-
(um; and I then mentioned several substances which, in their poisonous
action, alter the chemical constitution of the skin (den Chemismus
der Haut verändern), and, consequently, produce this affection.

Now, when the integument is exposed for a short time only to
the action of these substances, or when its resisting power is great,
a condition of hyperemia may be the only effect of their operation.
But these agents, as well as many others which likewise act chemi-
cally on the skin, may, in other cases, give rise to affections of a dif-
ferent kind, consisting sometimes in a simple dermatitis (attended with
redness and swelling, and with the development of vesicles, bullse, or
wheals), sometimes in the occurrence of either dry or moist gangrene,
with the formation of black, grey, or brown eschars, &c. Tor in-
stance, the former effect is produced by the Uhus Toxicodenäron and
the Mezeretim, and by the Pulex penetrans ; the latter, by the strong
mineral acids, the caustic potass, arsenic, and such compounds as
the Yienna paste,- or the pastes of Canquoin or Landolfi.

The treatment of the morbid changes to which I have applied the
name of Dermatitis venenata, and which are caused by these or
similar substances, must be conducted on the general principles which
I shall point out when I come to speak, under the head of Dermatitis
calorica, of the treatment of inflammation of the skin in general.

3. Dermatitis calorica.

Under this name I shall describe not only those inflammatory
conditions of the skin which are called into existence by the opera-
tion of heat, but also those produced by the action of cold. These
are termed, respectively, burns and frostbites (Verbrennungen and
Erfrierungen) .

' Vid^ p. 53, supra. " Vide p. 42, supra.

314 DERMATITIS AMBUSTIONIS.

a. Dermatitis ambustionis (Combustio) .

The appearances produced on the cutaneous surface by the action
of heat vary according to the degree of temperature to -which the
integument is exposed, the nature of the medium by which the heat
is transmitted, the extent of surface involved, and the constitution of
the individual. In general, we find that any elevation of the tem-
perature of the body above what is natural (ioo° Fahr.) causes the
cutaneous vessels to become hypersemic, and the skin to assume a
red colour. In other words, an erythema (the Erythema caloricum)^
is produced, the severity and the diu'ation of which are proportionate
to the intensity of the heat. If the temperature should once have
gone beyond 145° Fahr., the erythema does not subside when the
action of the heat ceases, disappearing only at the end of some days,
after which the part of the cuticle directly affected by the heat
undergoes desquamation. On the other hand, when the temperature
reaches 212° Fahr, (the boiling point of water), or is still higher,
the ej^idermis is destroyed by it, and the cutis exposed ; while, at
other points, inflammatory exudation is rapidly thrown out beneath
the cuticle, and produces bullae ; or, again, if the action of the heat
should be continued, charring takes place, and yellow, brown, or
black eschars are formed.

Thus, then, the appearances produced in the skin by burns may
be considered under three heads, or as presenting three degrees of
intensity.

ist Degree. — Dermatitis ambustionis erythematosa. Britlure (Rayer).

The symptoms of this, the mildest form of burn, are confined to
the parts affected by the heat ; they consist in a reddening of the
surface, of A'^arying intensity, but disappearing beneatli the pressure
of the finger, in a more or less considerable degree of swelling, and
in persistent pain.

The course of this affection differs in no way from tliat of the
ordinary forms of dermatitis due to any other cause. The first
change is the disappearance, by absorption, of tlie.-serous infiltration

Vide p. 53, supra.

DERMATITIS AMBUSTIONIS. 315

which occupied the cutis and gave rise to the swelling. Upon this,
the epidermis becomes the seat of a more or less intense pigmenta-
tion, and is seen to be divided by numerous little cracks and fissures,
so as to form minute scales. These, however, remain adherent for a
while, till they are compelled to peel off by the growth of healthy
cuticle beneath them. The whole morbid process then comes to an
end without any further change in the epidermis or cutis, and leaves
behind no trace of its existence.

These effects may be produced even by intense sunshine, if its
operation be continued for some time. This, however, is observed
especially in persons who rarely expose themselves to the direct rays
of the sun, or whose skin is peculiarly sensitive to the influence of
heat. But the action of radiant heat, proceeding from a body at a
very high temperature, and kept up for a considerable time, would,
no dnubt, give rise to similar appearances in every individual.

2nd Degree. — BennatUis amhiistioius bullosa. Briilure vesiw-
leuse et hvlleuse (Eeyer).

The characteristic appearance of burns of this degree is the
formation of vesicles or bulla, the epidermis being raised by serous
exudation accumulated beneath it. In some cases, however, when
the quantity of effusion is very large, or when the action is very
rapid — or, again, when the cuticle is not strong enough to retain the
fluid poui'ed out beneath it — the bullae quickly burst, and allow their
contents to escape. Under these circumstances, neither bullae nor
vesicles are to be seen ; but the epidermis, torn from the subjacent
cutis, is observed either as a white pulpy layer, or as a soft white
membrane, rolled up and lying on the surface of the true skin, which
last is then intensely reddened, and presents numerous bloody points,
produced by haemorrhage.

The degree of swelling and pain, in this form of burn, depend
partly on the extent of surface affected, partly on its anatomical
position.

The following are the changes which successively occur in burns of
the second degree : — The remnants of cuticle first become converted
into thin, pale yellow or brownish scabs. The cutis, being de-
prived of its epidermis, and, as we have seen, infiltrated with blood,
keeps pouring out a thin serous exudation which covers its sur-

olß DKRMATITIS AMBUSTIONIS.

face. In this fluid, pus-cells gradually develope themselves; and
the whole of the exposed surface becomes at length clothed with a
coherent puriform layer of a straw-yellow colour. If the access of
air be permitted, this next dries up into a pale-yellow or even dark-
brown scab, under the protection of which the healthy epidermis is re-
produced within a fortnight or a month, the time required for its
formation varying with the severity of the burn. Upon this, the
scab produced by the desiccation of the pus separates. The new
cuticle, which then comes into view, is thin and delicate, so that the
reddened cutis beneath can be seen through it. Even after this, a
secondary inflammation is sometimes set up, and fresh bullae may be
formed, of wliich the base is the seat of haemorrhage.

After burns of this kind, cicatrices may be altogether wanting ;
if present, they are flat, and covered with numerous small pits
(Grübchen).

Burns of the second degree are produced by boiling fluids, by the
transient action of flame, by contact with bodies intensely heated
(particularly if good conductors), and even sometimes by exposure to
radiant heat, if it be very intense and its operation long-continued.

The system generally is sympathetically affected in these cases ;
for febrile disturbance is present, of which the intensity varies with
the extent of the burn.

3rd Degree. — Dermatitis ambustionis escharotica. Briihire
gangreneuse (Rayer).

The appearance characteristic of burns of the third degree is the
formation of escliars, which are of an ash-grey, yellow, brown, or
black colour; and more or less dry, hard, firmly adherent, and
devoid of sensation. These eschars arise immediately after the
injury is received by the skin. Other parts of the surface generally
at the same time present the changes above described as belonging
to the less severe forms of burns.

It is not possible, from the form, colour, and thickness of the
eschars, to determine directly after the accident to what extent the
subjacent parts have been injured, as well as the tissues of the skin
itself. For the appearance presented by the eschars is nearly the
same when the muscles and even the bones have been destroyed, as
when the skin alone has been attacked.

j!^ow, for the purposes of diagnosis, and also in medico-legal

DliRMATiTlS AMBUSTIONIS. 317

cases, we require some character to indicate the severest kind of
burns; and it is desirable that we should, immediately after the
injury, be able to determine the presence or absence of this cha-
racter. Hence I am of opinion that, for all practical purposes, the
three grades which I have described are sufficient, and that we may
include under burns of the third degree those forms which Dupuy-
tren and others have spoken of as burns of the fourth, fifth, and
sixth degrees.

The eschars produced by the burning and charring of the tissues
vary in thickness, according to the intensity of the heat, and the
depth to which the destructive action has extended ; and in propor-
tion as they are thicker, they take a longer time to become com-
pletely separated and cast off from the uninjured structures beneath,
bj the suppurative action which takes place around them. Within
a few days after the accident, a yellow purulent border may be ob-
served at the margin of the eschar, gradually extending more deeply
towards its base, and forming a line of demarcation by which the parts
charred are separated from those which remain healthy. When this
has occurred at every point, the eschar falls off, leaving a more or
less extensive loss of substance, or, in other words, a wound, which
is generally clean and suppurating, and is covered by peculiarly
sensitive granulations. The loss of substance is repaired in the
usual manner, and, as the surrounding skin contracts greatly, there
is formed a raised, cord-hke or radiating cicatrix, which is of more
or less thickness, and often, by forming contractions and adhesions,
gives rise to great deformity.

The general symptoms produced by burns of the third degree
arise, for the most part, not immediately after the accident, but sub-
sequently ; so that the danger of the patient^s condition is not at
once obvious to those who have but little experience of such cases.
It is often only when the eschars have become completely cast ofl^
and when suppuration is in progress, that febrile symptoms set in,
or that the affection becomes serious, and even dangerous.

The fatal result in cases of burns is sometimes due to a state of
exhaustion, itself caused by the intense action on the nervous system
in general, this intense action being indicated by the ])rescnce of
very great pain, or even by the occurrence of convulsions. In other
instances, the cause of death is the absorption into the blood of
putrid or decomposing pus. When this occurs, severe shivering
grncvally sets in, and metastatic deposits take place in the hiternal

318 DERMATITIS AMBUSTIONIS.

organs, giving rise for the most part to lobular pneumonia or to
pulmonary gangrene. Or, again, disease of some of the viscera
may arise : thus Rokitansky and other pathological anatomists have
observed intestinal haemorrhage to occur after burns.

Burns of the highest degree of intensity are produced only by
some intense source of heat ; as, for instance, when the skin is ex-
posed for some time to the action of flame, or when red-hot iron
or other red-hot bodies are allowed to remain in contact with the
skin, or, again, when the clothes have caught fire.

Prognosis. — In burns of the first and. second degrees, a favorable
prognosis may in general be given, the only exception being when a
bui'u of the second degree is very extensive ; as, for instance, when
the whole surface of the body is scalded.

Burns of the third degree, however, even when of but small
extent, are always dangerous injuries. According to most observers,
they invariably terminate fatally when more than one third of the
cutaneous surface is injured. In reference to prognosis, it is also
of primary importance to consider how deeply the tissues have
imdergone destruction, what is the part afi'ected, and what the
Indiciduality of the patient : especially what are his age, sex, and
bodily constitution, and what the previous diseases from which he
may have suffered.

Treatment. — The treatment of burns must, in the first place, vary
witli the severity of the injury. In cases in which the epidermis is
uninjured, and the cutis merely hyperferaic, or the seat of hsemorrhagic
infiltration, or even of serous ciFusion into its substance, all treat-
ment is superfluous, except in so far as it may be required to alle-
viate pain, or to diminish the engorgement of the cutaneous blood-
vessels. Thus, cold wet rags may be applied, or any bad conductor of
heat, such as the well-known popular remedies, mashed potatoes or
can-ots, and clay. Some of the substances generally used, such as
cotton-wool and joiner's glue, probably act through the imagination
alone.

In burns of the second degree, in wliich the cutis is deprived of
its covering at certain points, the principal indication is to prevent
the access of air to those parts, so as to favour the restoration of
the cuticle by the natural processes, and relieve the painful impressions
conveyed by the cutaneous nerves. Hence, the bullse.should, if jDOssible,
be left untouclied; or, if it is necessary to evacuate their contents,

DERMATITIS AMBUSTIOMTS. 319

a small puncture should be made at the lowest point of each bulla,
care being taken that its roof afterwards comes into contact with
its floor. The applications best suited to these cases are certain
well-known oilv or viscid liquids (such as collodion or glycerine), or
the ordinary liniment, made of equal parts of linseed-oil and lime-
water, or of olive oil and yelk of egg. These local remedies
will, in most instances, be sufficient. We may apply to the injured
parts either the liquid itself, or compresses dipped in it, cold wet
rags also being employed in any case.

It is, however, well to adopt a different treatment when burns
occur at certain parts (such as the folds opposite the joints of the
fingers and toes, and the flexor surfaces of the joints generally), at
which there is reason to fear that adhesion of the opposed surfaces
may take place, during the process of healing. Under these circum-
stances, the nitrate of silver may be used with great advantage. It
may either be applied eii crayon, the denuded parts of the skin
being touched with it once or twice daily ; or it may be employed in
solution (containing equal parts of nitrate of silver and distilled
water), in which pledgets of lint are dipped, which are then laid upon
the spots deprived of their epidermis. Tlie black eschars thus pro-
duced must be removed as soon as they can be separated from the sub-
jacent parts, the caustic being at once applied, so as to form fresh
eschars. This procedure must be repeated again and again, till the
eschars produced by the application of the nitrate of silver adhere so
firmly that it is difiicult or even impossible to detach them.

A burn of the second degree, treated in this way, heals for the
most part much more quickly, is not followed by raised cicatrices,
and does not give rise to adhesions of the fingers or toes, or of the
opposed surfaces of the joints, such as there would otherwise be
reason to dread.

The preparations of lead (such as the Goulard water, the liq?wr
plumhi subacetaiis, or the ung. jduriihl carhonatu) may also be
applied with success in these cases. So far as my experience goes,
there is no ground for the fear which some have expressed, that
the lead may be absorbed and give rise to the symptoms of poisoning
by that metal.

The eschars produced by burns of the third degree may be very
thick when the tissues have been destroyed to a great depth, and
their separation may, consequently, take a long time, which cannot
be shortened by any method of treatment. During this period,

320 DERMATITIS AMBÜSTIONIS.

the only local applications which should be used are such as relievo
the pain experienced by the patient. Por this purpose we may
employ, sometimes cold wet rags, sometimes warm fomentations,
the important point being to keep the injured parts moist. The
various ointments and plasters are obviously useless, and even inju-
rious ; for their application would rather interfere with the separation
of the sloughs, while it would at the same time favour the retention
of pus and of unhealthy discharges. The employment of caustics
is equally uuadvisable, for they give rise to needless pain and do
the ])atient no good whatever.

The practice of continuous irrigation, on the other hand, is of
great value, whenever the situation of the burn permits its employ-
ment. Its advantage is twofold : it tends to prevent the access of
air ; and it also facilitates the cleansing of the raw surface, and
diminishes the pain which the patient suffers. In the case of bui'us
confined to any part of one limb, this treatment may be carried out
by a most simple form of apparatus. All that is required is a can
filled with water, and having a spout, which is provided with a stop-
cock, and connected with one end of a flexible tube, of Avhich the
expanded termination is placed immediately over the part affected.
AVheu the stopcock is slightly turned, the water flowing down the
tube falls upon the inji\red surface, and trickles over it into a vessel
placed beneath.

To enable me to carry out a similar plan in cases of more exten-
sive bm-ns, I have had a special apparatus constructed. This con-
sists of a bath, six feet long by three feet broad, made of wood, and
lined with copper or zinc. Exactly fitting its interior is an iron
frame to which are fastened transverse bands of webbing, as in an
ordinary bed. At about two feet from one end of this frame is
attached a head-support, which moves on a hinge, and can be fixed
at any angle by a simple piece of rackwork. The frame is covered
with a blanket, and is also provided with a horsehair pillow ; it does
not rest on fixed supports, but is suspended in the bath by cords
attached to it at either end. These cords pass over two small
rollers, placed one at the head, one at the foot of the apjDaratus, and
provided with handles, so that the whole bed can easily be raised or
lowered within the bath. At the head of the bath, but at a higher
level, is a vessel made of copper, which can be heated, so that the
water may be supplied at any required temperature. The supply-
pipe enters the bottom of tlie bath, tlie escape-pipe opening into it

DERxAlATlTlS AMBUSTIONIS. 321

at the water-level. When the apparatus is in use water is kept
constantly flowhig through it^ so that all impurities are rapidly
washed away. To enable the face to be kept continually wet, or to
be specially irrigated, additional small tubes, each provided with a
rose, are connected with the copper vessel. These tubes may also
be used for the irrigation of any part of the body, the patient being
in that case kept raised above the level of the water in the bath.

Before the patient is placed in the bath, it is filled with warm
water, at a temperature of 90° to 100° Fahr., according to his
inclination. The water is also entirely changed every day.

A wooden cover, upon which a blanket is spread, is put over the
lower part of the apparatus while the patient is in the bath. If he
wishes the head also to be covered this is easily managed by roofmg
in the head of the bath by means of hoops, upon which blankets
are placed.

It is obvious that this apparatus requires continual attendance.
It might be thought that there would be some danger of the patient
being drowned during sleep ; but this does not appear to be the
case; nothing has occurred in the course of the experiments hitherto
made to sua'o-est the slightest fear of such an event.

I have already, in the chapter on Variola,^ cursorily alluded to
this apparatus, which I have used in certain chronic skin diseases
(such as psoriasis and pemphigus), as well as in smallpox and in
burns. I have found by experience that persons may remain for a
hundred days uninterruptedly, day and night, in a Avarm bath, \nth-
out injury to their health. Accurate observations, written down
from hour to hour, show that neither the pulse nor the respiration
nor the temperature of the body has undergone any marked change
in persons placed in the continual bath. There has been no loss of
appetite, and the patients have continued to sleep well. The
amount of urine secreted, however, has been much diminished.

1 have hitherto^ tried this method of treatment in only three cases,
which are far too few to enable me to draw any conclusions as to its

' Vide supra, p. 267.

2 Prof. Hebra informs me by letter that, in order to favour the local action
of tar or other applications, he still uses the bath in cases of various skin
affections, keeping the patient in warm -water for several hours, or even for a
still longer time. In severe burns, although it does not save the patient's
life, it always relieves the pain which he suffers. Four of these baths have
been put up in the General Hospital of Vienna.

The detailed account of the continual bath in the text is taken from the dc-

322 DERMATITIS CONGELATIONIS.

value. I .shall therefore content myself with pomting out the prin-
ciples on which its application depends^ and refer my readers for
further information to a special work which will hereafter appear.
I believe that the use of the continual bath will at any rate give
results not less favorable than those of the methods of treatment
hitherto employed with a similar object.

These have consisted either in the application of absorbent sub-
stances, such as powdered charcoal, to remove the gangrenous dis-
charge and prevent its remaining in contact with the surface of the
Avound, or in the use of remedies which are regarded as antiseptics,
such as the aqua vulneraria,^ vinegar, pyroligneous acid, or creosote.
In praise of such applications the surgical text-books say a great
deal which, unfortunately, is not warranted by experience.

Other parts of the treatment, such as the removal of tissues of
which the vitality is already destroyed, are matters of surgery, upon
the description of which I cannot in this place enter ; and I also
think it unnecessary to give a detailed account of the management
of the febrile symptoms, the metastatic diseases, or any of the other
complications which are apt to make their appearance in cases of
burns.

h. Dermatitis congelationis.

In the inflammations of the skin produced by the action of cold,
gradations may be recognised which bear a general resemblance to
those observed in cases of burns. For the skin is, in frost-bites,
sometimes merely reddened and swollen, while, in other instances,
vesicles and bullae are formed ; and in a third class of cases the
cuticle is destroyed, and excoriations or even eschars make their
appearance.

The slow course taken by these complaints is, however, a pecu-
Uarity which distinguishes them from the inflammatory afPections of
the skin set up by the action of heat. For burns — at any rate, the
less severe forms of them — very quickly subsid«, the healthy state

scription of it by Prof. Hebra, sent with a specimen of the apparatus, placed in
the International Exhibition of 1862. It is also fully described, and a plate of
it is given, in the 'Wiener Allgemeine Med. Zeitung,' No. 43, 1861. — [Ed.]

' A liquid obtained by distilling various aromatic herbs with dilute spirit.
Jourdan, 'Pharm. Univ.' — [Ed.]

DERMATITIS CONGELATIONIS. 323

being at once restored, except that there remain portions of the
epidermis which has been destroyed. But in the case of frost-bites
we have to deal with inflammatory action, and its results, long after
the cold has ceased to be in operation.

The affections with which Ave are now concerned are further dis-
tinguished by the fact that a certain morbid disposition on the part
of the patient is a necessary condition of their occurrence. For
experience shows that when several persons are exposed to the action
of cold at the same time and in the same way, some of them only
suffer from its effects, the others escaping altogether.

Moreover, we observe that in some persons an extreme degree of
cold is not required for the formation of chilblains (Frostbeulen) on
parts of the body exposed to its influence. Indeed, even a tem-
perature not below 32° Pahr. may produce a reddened and swollen
condition of the hands and feet of young people, or, in other words,
the appearances of congelatio. This occurs especially in hot coun-
tries, in which chilblains are well known to be more common than
in colder regions ; this being due to the fact that the arrangements
for heating apartments are generally badly constructed in warm
climates, and the rooms themselves ill-adapted for cold weather.
Moreover, in these countries chilblains often affect people in good
circumstances, and not merely those who belong to the labouring
classes, and are consequently exposed to severe cold.

Now, we find on investigation that persons, whether males or
females, who are particularly prone to these affections are of a
particular constitution, and in a similar state of health. The
skin is, in these individuals, of a pale colour, and often infiltrated
Avith serum, so that the face has a doughy (gedunsen) appear-
ance. If the ])atient is a girl, she suffers to a greater or less
degree from chlorosis; Avhile the males are of the so-called
lymphatic constitution and of lax muscular fibre. Hence it is
obvious that the same condition, namely, one of oligcemia, or (more
correctly speaking) aglobulosis, is to be regarded, in both sexes,
as the predisposing cause of chilblains, besides being, according to
niy experience, associated with a special tendency to various forms
of cutaneous disease. That this is really the case is surely proved
by the fact that the liability to the occurrence of chilblains subsides
Avhen the bodily constitution of these individuals is altered. Thus,
chlorotic girls, Avho were always affected with them during autunm,
Avlien tlie temperature Avas not below 43*^ Falir., no longer suffer

324 DERMATITIS CONGELATIONIS.

from them if their anaemic condition is removed, whether by the
administration of medicines or by some aheration in their state of
life, such as theh being married or becoming pregnant.

1st Degi'ee. — Dermatitis congelationis eri/theniatosa, Pernio
(Chilblain, Frostbeule).

This is an affection of certain circumscribed portions of the skin,
which acquire a livid red colour and a somewhat tubercular (knoten-
artig) appearance ; the colour disappears beneath the pressure of the
finger. Chilblains are attended with itching, or with a burning
pain ; they occur especially on the fingers and toes, but may appear
also on the ears, nose, or other parts of the face, or, indeed, on any
part of the body Avhicli is exposed to cold of some intensity.
When the temperature rises, and especially when the part is
exposed to the action of heat, these appearances sometimes undergo
no change, sometimes become still more marked. Under these cir-
cumstances the colour of the parts affected is altered, changing from
a dark bluish-red to a bright rose-red tint.

With the exce])tion of these slight variations chilblains remain for
a long time in a stationary condition. They may, indeed, become
worse at certain periods ; this occurs most commonly in the cold
season of the year, being, however, sometimes observed even during
summer ; but in that case the only alteration is an increase in the
amount of redness and swelhng, there being no change whatever in
the essential characters of the complaint.

In certain cases, however, chilblains do undergo metamorphosis.
Thus, they may become harder than usual (an Cousistenz zu-
nehmen). In other instances the skin of the part affected by
them grows extremely vascular, so that they present a very deep
livid hue. At the same time the cutis becomes more tough than
before, and the epidermis also undergoes change, becoming thin,
smooth, and satiny, being traversed by indistinct furrows, and pre-
senting various shades of colour (schillernd).

Sometimes, again, the metamorphosis is of' a different kind.
Under the influence of certain mechanical conditions (such as fric-
tion or scratching, or the pressure of boots or shoes) changes occur
in the exuded matters, and either a sero-sanguineous or a purulent
fluid is formed beneath the e])idermis, so as io produce a bleb
or a pustule. The mere presence of such bullae or pustules is

DERMATITIS CONGELATIONIS. 325

attended with paiu^ Avliich; however^ increases when they bursty ex-
posing the papillary stratum of the cutis. This form of the affection
is the suppurating chilblain {Pernio suppurans, Frostgeschwiire) .

These changes frequently lead to the cure of the complaint. For
after the breaking down (Schmelzung) of the exudation the ulcerated
surface heals over, and a cicatrix is produced, so that the part can^
not readily become again hyperBemic.

and Degree. — Dermatitis congelationis bullosa.

Under the influence of a more intense degree of cold we often find
that bullae are formed, which may be of the size of hazel-nuts or
even as large as gooseys eggs. The fluid which they contain
may be either watery and transparent or sero-sanguineous. If they
are not punctured they undergo no change for some time, but at last
break, upon which the tissues beneath are found to be destroyed to
a greater or less depth. Indeed, when such bullae appear on the
feet and hands (their favorite seats) the bones are often exposed, the
soft parts between them and the skin having been completely de-
stroyed. The losses of substance thus produced may be considerable ;
indeed, entire phalanges sometimes exfoliate, their ligaments and
tendons having previously sloughed away.

In less severe cases, however, the destruction to which this ulcera-
tive process gives rise is not so extensive, and cicatrization occurs.
But even then scars are always left, which interfere to some extent
with the usefulness of the part.

For the production of such efi'ects as I have been describing, it is
by no means necessary that the part should have been exposed for a
long time to the action of intense cold. On the contrary, these
affections may be generated in the course of a few hours, particularly
upon the hands and feet. They are observed most frequently in
persons who have travelled long distances in carts during very cold
weather, with their feet insufficiently covered, or who have been
occupied in clearing away snow or in breaking ice.

3rd Degree. — Dermatitis congelationis escharotica.

The affections which come under this head present different
characters. In some cases there appear bullae filled with bloody

320 DERMATITIS CONGELATIONIS.

semni, beneath which one can, from the first, see gangrenous patches
of a dark or a reddish black colour. In other instances eschars are
produced directly, without any such bullEe being formed, and de-
stroy the soft parts to a greater or less depth, and even the bones
themselves. The parts which have undergone these changes are cold
and perfectly insensible, and the patient suffers no pain whatever,
even at the borders of the gangrenous patches, where these are in
contact with healthy tissues. Indeed, when the tips of the fingers
or toes are affected with this form of gangrene he often goes about
as usual for some considerable time. The eschars are, in these
cases, very slowly detached and cast off, months often passing before
they become completely separated from the living tissues and alto-
gether removed from the body. Moreover, it is to be remarked that
the separation effected by the natural processes is generally very
incomplete and irregular, and that in most cases certain parts
(such as the phalanges of the fingers or toes), which interfere with
the healing of the wounds, have to be removed by surgical inter-
ference.

When the gangrenous action remains limited to the parts directly
attacked by the cold, and when none of the constituents of the dead
tissues are absorbed into the circulation, the affection may run its
whole course without any disturbance of the general health. But
when the blood becomes contaminated with unhealthy matters in
consequence of the absorption of the gangrenous fluid, or of pus
formed while the reparative processes are going on, the well-known
symptoms of pyaemia present themselves, and under these circum-
stances the case may even terminate fatally.

Treatment. — In considering the treatment required for chilblains
and frost-bites it must not be overlooked that, at any rate in the less
severe forms of these affections, the great practical difficulty lies in
the removal of the obstacles which prevent the disease from getting
well. Patients, in fact, ask to be cured without being obhged to
give up the occupation which made them liable to be affected with
the complaint, or having to avoid the exciting cause, whatever that
may happen to be, which gave rise to it. Thus, a person who has
to work in the open air, and is, in consequence, tormented MÜth
chilblains on the hands, demands a remedy from the physician, but
remains out of doors as much as before. And yet, when the treat-
ment recommended does not lead to the good results which were

DERMATITIS CONGELATIONIS. 327

hoped for by both patient and doctor, the want of success is attri-
buted to the inefficacy of the remedies, and not to the fact that the
cause of the complaint is still in operation. This applies also to
those conditions seated within the organism itself, ^yhich have al-
ready been referred to as predisposing to these affections. It is not
in our power to remove these conditions instantaneously, but till
this is effected the patient will remain liable to the complaints which
depend upon their presence. It is necessary to take these points into
consideration before giving a prognosis, as well as in prescribing for
such cases.

If we have to deal with a simple recent chilblain, affecting an
indiAadual otherwise healthy, the mildest antiphlogistic measures will
be sufficient to relieve or cure the dermatitis, pro\dded only that the
patieut can and will avoid aU further exposure of the part to cold
while he is under treatment. Tlie horizontal posture, the applica-
tion of wet rags, the use of frictions with cold water or snow, are
universally known and approved remedies ; and hundreds of persons
affected with chilblains are every year ciu'ed by these simple methods.
I consider it far wiser to employ treatment of this kind than to
prescribe leeches, ice-bags, lotions of sal ammoniac, or any other of
the more powerful ant'qMof/istic agents, as they are termed. For it
wiU be found difficult to prove that the appKcation of a leech
can remove blood from a part which is hj^^ersemic or inflamed,
without the same quantity at once passing from the adjacent
tissues into the dilated vessels of the part affected. I should be
more disposed to recommend the employment of scarifications, pro-
vided that the incisions are carried to a sufficient depth, for this
practice does at least effect the destruction of some of the blood-
vessels which go to the part, and must, therefore, relieve the tension.
TMiether or not any advantage is gained by prescribing lotious
containing sal ammoniac, preparations of lead, alum, or other
astringents, instead of merely using cold water, has yet to be proved.
I do not at present admit that such applications exert any beneficial
action, and, therefore, I always confine myself at first to the use of
wet rags, and continue to employ them as long as they are agreeable
to the patient, and mitil I find that the symptoms of conges-
tion— the reddening of the surface, the increased temperature, and
the perverted state of the sensibility of the part — have disap-
peared.

When chilblains have already existed for a long time, or have

328 DimMATITTS f'ONGELATIONIS.

undergone a relapse, it becomes our aim, not merely to relieve the
part of the blood with which it is overloaded, but also to remove
the permanently distended condition of the vessels, or even to cause
the inflammatory exudation to liquefy or break down and to be ab-
sorbed. To effect these objects the antiphlogistic treatment above
described is scarcely sufficient, and we must rather employ local
applications of a slightly stimulant nature, and such as favour the
occurrence of absorption. Experience has supplied us with a con-
siderable number of such remedies ; and in some cases, if they do
not completely remove the complahit, these substances give marked
relief to the unpleasant sensations experienced by the patient, and
particularly to the itching. Under this head may be enumerated
the vegetable and mineral acids (such as the pyrohgneous acid, the
dilute nitric or hydrocliloric acid, and lemon juice), creosote, chlo-
ride of lime (Chlorkalk), caustic lime (Aetzkalk), tincture of iodine,
collodion, camphor, &c.

Yarious aj^plications are popularly employed for the cure of
old chilblains. Among these are joiner^s glue, honey, and the so-
called animal baths^ (animalische Bäder), including baths made
with guano. That these applications have any therapeutic value,
I neither assert nor deny.

Eeal benefit, however, is derived from the employment of pressure
in the case of chilblains seated on the lingers or toes, or on any other
part which admits of its application. The common adhesive plaster
may be used for this ])urpose ; but the simplest plan is to employ
narrow tape, wound tightly round the finger or toe, from the extre-
mity upwards, after the mamier of the Theden'sche Verband, applied
in fractures of the phalanges.

Excoriated, suppurating, or ulcerated chilblains are, of course, to
be treated in the same way as similar affections arising from any
other cause ; but even in these cases water shoidd, as far as pos-
sible, be made use of as a local application, either cold wet rags
or warm fomentations being employed. But as this can be done
only Avhen the patient gives hunself up entirely to the treatment
and remains in bed, we are often obliged to direct that some plaster
or ointment should be apphed. Eor this purpose I can especially

^ Prof Hebra has informed me by letter that when a patient is affected with
clironic swelling of a limb, the part is often introduced into the second
stomach removed from a recently slaughtered ox or other ruminant, under the
idea that the animal heat will soften the inflammatory material. — [Ed.]

DERMATITIS CONGELATIONIS. 329

recoimueiid the^ Emp. Litliargyri Fusciim^ or Emp. clomes-
ticum.

In frost-bites of the second degree, when bullse are present, the
treatment AThich I have found most successful is the so-called
ectrotic method, which consists in puncturing the roof of the bleb
with a pointed stick of nitrate of silver, and rubbing the caustic
firmly over its base. As soon as the eschar thus produced can be
removed, I again apply the nitrate ; and I continue to use it in the
same way until the surface of the wound appears clean and covered
with granulations. This practice has sometimes prevented the ul-
ceration w^hich follows the rupture of the bullEe from extending
deeply and destroying the tissues beneath.

"When the action of cold has led to the formation of eschars, the
first thing is to effect the removal of the parts which have under-
gone mortification ; and when this would be but slowly and imper-
fectly accomplished by the natural processes, we must have recourse
to the ordinary operative measures.

^ Emp. Fuscum (Brown Diachylon). (Minium 8 oz., olive oil i6 oz.,
yellow wax 4 oz,, camphor 2 dr.) — The colour is given to this preparation by
boiling the minium and the oil together, till a brownish-black mass is formed.
Jourdan, ' Pharm. Univ.' — [Ed.]

CHAPTER XIV.

ON THE DERMATITIDES PROPER.

(CLASS IV.— ACUTE, NON-CONTAGIOUS, EXUDATIVE

DERMATOSES.)

B. Dermatitis symptomatica.

I. Dermatitis erythematosa.
(Superficial symptomatic inflammation of the skin.)

Erysipelas.

{Dermatitis symptomatica, Rosa, RotJdauf, Hautrose, Ihysipele,

Risipola.)

Erysipelas is that cutaneous affection in which the skin is swollen
and hot, and of an intense, diffused, red colour, disappearing beneath
the pressure of the finger; in which vesicles, bullse, or pustules,
sometimes appear; which is attended ^\i\\\ febrile symptoms, and
with sensations of tension or of bm-ning pain ; and which, when it
terminates, is followed either by desquamation only or by the forma-
tion of crusts.

This disease has been compared to the exanthemata by recent as
well as by the older writers ; and even if it has not been attri-
buted to any definite contagious piinciple, it has at least been
ascribed to a special and peculiar crasis. For my part, I cannot
express my concurrence in this view. I regard erysipelas as a com-
mon inflammation of the skin, capable of being excited by various
causes, some of which have their seat in the integument itself, while
others arise from affections of other organs, or have an origin as
yet unknown to us. Thus, I am as little disposed to admit the
existence of an erysipelatous crasis of the blood as to account for

ERYSIPELAS. 331

the occurrence of epidemics of this disease by referring them to a
special contagious principle.

Symptoms.

Several writers have thought fit to admit in erysipelas (as in the
exanthemata) distinct periods or stages, namely, a stadium pro-
(Iromorum, d^ st.eruptionis, a st.ßoritionis, and a st. äesquamatioim.
Now, it is, of course, undeniable that erysipelas breaks out, reaches
its acme, and afterwards declines ; and consequently its whole course
may be arbitrarily divided into such stages. But these do not, in
the case of this disease, rest on the same firm basis as in the
exanthemata. They are not definite enough in themselves, nor
are they sufficiently characterised by special symptoms. More-
over, the different phenomena do not, in erysipelas, follow one
another in regular order, nor are the divisions which have been
fixed upon uniform and of determinate length, as they are in the
exanthematic fevers. Tor these reasons it ap])ears to me that I
may with advantage abstain from dividing the course of this com-
plaint into distinct periods.

However, I think it well to arrange the symptoms of erysipelas in
iliree groups, exactly as I did those of morbilli, scarlatina, and variola ;
the first of these groups including the appearances presented by
the skin; the second, the febrile phenomena; and the third, the
symptoms due to affections of the different organs of the body, the
skin excepted.

I. Cutaneous aj)pearances. — Erysipelas generally begins at some
particular spot, the skin over a cu-camscribed space of perhaps
the size of a walnut becoming shghtly swollen, and of a shining
red colour. On the appHcation of pressure the redness disappears,
and when the finger is removed, the part is at first seen to be of a
yellow hue, but quickly again becomes red. The patient, at this
time, complains of slight pain or itching.

In the course of the first twenty-four hours the disease spreads
to a greater or less extent from the spot originally attacked to
the adjacent parts of the cutaneous surface, which are now affected
in a similar way ; in other words, erysipelas diffuses itself per con-
iiguum. Thus, at the end of this time it covers a tract as large as
the palm of the hand, and after another period of the same length

332 ERYSIPELAS.

it will have extended over a space of double that size. After the
lapse of seventy-two hours the complaint has generally reached
a limit, within which it is confined during the whole of its further
course ; at any rate, after this time it usually remains stationary for
several days. The redness is now very deep, with a tinge of blue
or yellow, particularly at the border of the part affected ; the
amount of swelling, and, consequently, the degree of tension, vary
in different cases, but are sometimes very considerable ; the surface
is smooth and shining, as if oiled {Erysipelas glahrum) .

Presenting these appearances, erysipelas reaches its acme when it
ceases to spread ; it then receives the name of Erysipelas fixum.

After this time the tension gradually diminishes, the surface of
the skin has no longer a shiny appearance, the epidermis becomes
again furrowed, and the intense red colour of the part affected passes
into a darker hue. Still later the cuticle begins to peel off, forming
lamellae or shreds of greater or less size, and this desquamation is the
last local symptom of the disease in cases which run the ordinary
favorable course.

2. Febrile symptoms. — The appearances of dermatitis above de-
scribed are generally preceded by symptoms of fever, or, in other
words, by shivering, followed by subjective sensations of heat and
elevation of the temperature of the skin, acceleration of the pulse
and respiration, great depression and lassitude, pains in the joints,
urgent thirst, and high-coloured urine. These symptoms continue,
with more or less intensity, until the tension and swelling of the
skin begin to decrease ; afterwards, as a rule, subsiding in propor-
tion as these diminish, and as the cuticle begins to peel off. By
the time that the desquamation is fairly in progress all the febrile
symptoms have generally disappeared.

3. Concomitant symptoms. — In many cases of erysipelas these
are altogether ^wanting, the tongue being clean, and there being a
complete absence of nausea, vomiting, diarrhoea, and every other
sign of disorder of the digestive tract. But in other instances, and
sometimes even in mud forms of the disease, symptoms of a trifling
gastro-intestinal catarrh (Gastricismus) are present, or signs of slight
cerebral irritation or pressure, or, lastly, such as point to some affec-
tion of the circulatory or respiratory organs.

VARIETIES. 333

Varieties of Erysipelas.

I. In regard to its form.

The exudation which causes the swelling in this disease is not
always diffused uniformly throughout the tissues of the integument.
Tor in some cases a serous fluid is poured out beneath the epi-
dermis at certain points, and forms vesicles or bullae of more or less
size, the ordinary form of the complaint being thereby converted
into an Erysipelas vesicidosum or E. Imllosiuii . The fluid contained in
such vesicles or bullae is largely albuminous, and has always a
neutral or feebly alkaline reaction. When examined microscopically,
it is found, from the very first, to contain a few pus-cells.

These vesicles or bullse are liable to various changes. Sometimes
they burst, whereupon their contents escape, their roof of epider-
mis sinks in, and brownish scabs are formed. In some cases,
however, the whole of the fluid contained in these vesicles or pus-
tules dries up, with the epidermis which covers them, into crusts
more or less thick, Avhich are cast ofP when the rest of the cuticle
undergoes desquamation. In other instances, again, the serous
fluid, at first transparent or yellowish, becomes turbid, like whey,
and afterwards straw coloured. It is, in fact, converted into pus,
as is evident not only from its appearance, but also from its con-
sistence and its more decidedly alkaline reaction, as weD as from its
microscopical characters. This form of the disease is the Erysipelas
pustulosum ; and, when the contents of the pustules have dried up
so as to form thick crusts, it constitutes the Erysipelas crnstosum
of the older writers.^

The E. vesiculosum, E. hullosum, and E. pustulosum, frequently
occur in combination, or are developed the one from the other in
the same patient. Thus, the affection may begin as an E. glahrmu,
and become successively vesicular, bullous, and pustular, without

^ I cannot but avail myself of this opportunity of drawing attention to tlie
fact that our forefathers incorrectly applied the same names {Erysipelas pus-
tulosum, E. crustosum) also to cases of acute eczema. Agaiu, the term Erysipelas
unomalum (wilder Rothlauf) was used by these writers for the Eczema impetigi-
7iosum, particularly when it affected the face and took a more chronic course.

According to the definition of erysipelas which I have given, it is, of course,
obvious that such affections do not belong to this disease.

334 ERYSIPELAS.

deviating in any other respect from the ordinary characters and
course of erysipelas.

2. In regard to its extent.

In a considerable number of cases^ whether of the E. glahrum,
E. vesiculosum, or E. pustulosum, the affection, occupying originally
a very small part of the cutaneous surface, at once spreads from
the spots at which it first appeared to the adjacent portions of the
integument. Indeed, diffusing itself in this way, it may succes-
sively invade large tracts of the skin, and even cover the Avhole sur-
face of the body. \Ye then observe that the borders of the erup-
tion present different appearances. In one direction the redness
shades off gradually into the normal colour of the skin^ having, so
to speak, a " washed-out^' (verwaschen) appearance : whereas, on tlie
other side, the redness and swelling terminate in a sharply defined,
raised edge; and this is always the side at which the erysipelas
is spreading to the adjacent healthy parts.

Corresponding to these differences, the subjective sensations of
the patient are likewise of a different kind. Along the line first
described (where the redness passes gradually into the normal colour
of the skin) pressure gives rise to no pain; while the opposite
border, limited by the raised edgCj is very tender on pressure, and sen-
sitive even to the slightest touch. Hence, in the erratic form of ery-
sipelas, the pain experienced by the patient when the skin is touched
enables us to recognise the extension of the disease to the scalp, or
to any other part where the presence of hair prevents our de-
tecting the reddened state of the integument. As I have already
stated, this variety of erysipelas may gradually spread over large
tracts, or, indeed, over the whole surface of the body ; but in
this case it may not be very widely diffused at any one time. The
skin of any part recently affected by it always has a yellow tinge ;
and a few scattered pustules are sometimes to be seen when it has
subsided ; or it may even be followed by a patch of dermatitis of
the circumscribed variety, or, in other words, by the formation of a
furuncle or an abscess. Sometimes, too, after having wandered over
a large part of the cutaneous surface, it appears for the second time
on the skin of regions once before occupied by it. In these ex-
ceptionally severe cases the febrile symptoms never entirely subside,

VARIETIES. 335

aud generally undergo exacerbation each time that the complaint
spreads to fresh regions. Moreover^ the whole character of the
disease and the course which it takes are far more unfavorable
than in the ordinary form of erysipelas; indeed, this migratory
variety terminates for the most part fatally.^

3. Li regard to its seat.

Any part of the cutaneous surface may be attacked by erysipelas ;
indeedj "we find in books descriptions of cases in whicli the whole
body is said to have been affected by this disease. It was to this
rare affection^ the Hrys'ipelas universale, that the names Kieropyr^
Ignis sacer, Ignis Sancti Ignatii, were especially applied. But, as
a rule, erysipelas is confined to some particular region of the body.

I. Erysipelas faciei. — Of the local forms of this complaint, that
affecting the face is certainly the first in order of frequency. It
generally begins on the nose or forehead, and afterwards spreads in
all directions. Eor the most part, however, it does not extend be-

' In giving an account of the migratory variety of erysipelas I cannot avoid
referring to the form of inflammation of the skin generally known under the
name of absorbent inflammation (Lymphangioitis). In fact, the only difference
between this affection and that which I have been describing is that ab-
sorbent inflammation is less intense, and is confined to those parts of the skin
beneath which lie the larger subcutaneous vessels, and, consequently, the lympha-
tics also. As is well known, this disease may arise from some slight wound,
or from an ulcer or abscess, or even a mere pustule or excoriation, seated on
one of the upper or lower limbs. It consists in the formation of strise, the
breadth of a finger, aud having a rose -red colour, and of small raised swellings
(kleiner wulstiger Elevationen). These appearances follow the course of the
vessels aud nerves, always advancing towards the trunk from the distal parts
of the limb. The red colour of the lines is sometimes interrupted at certain
points, reappearing, however, higher up, in the form of maculae. These striae
extend upwards as far as the nearest absorbent gland, which likewise becomes
swollen aud tender. Indeed, pain is also produced by pressure over the red
lines themselves, at any part of their course. The presence of absorbent in-
flammation on any one of the limbs generally prevents the part from being used
by the patient, for every movement of it gives rise to very severe pricking
pain. Like the erratic erysipelas, this aflection, when it subsides, leaves either
deposits of pigment, of abscesses of greater or less size, or indurated cord-like
elevations.

336 ERYSIPELAS.

yond the face, so that it may be named an Eri/sij^elas fiximi
faciei. When this is the case the affection is limited above by the
scalp; in the opposite direction it extends downwards towards the
laryngeal region; while its lateral boundaries are formed by the ears,
which are reddened and swollen, and project outwards from the side
of the head. The eyelids are very oedematous and swollen, and can-
not be opened, and the conjunctiva is often involved. The skin of
the nose is tense and shining ; the lips are so much swollen that they
cannot be closed, and, consequently, the tongue becomes dry, and
there is a continuous flow of saliva and buccal mucus from the
mouth.

When erysipelas of the face, from being fixed, becomes migratory,
its extension generally escapes notice for a time, because it occurs in
the direction of the scalp, where its discovery is interfered with by
the presence of the hair. But, as I have already stated, the patient,
under these circumstances, complains of severe pains in the liead, in-
creased by pressure, and even by the contact of a pillow ; and this
should draw our attention to the fact that the disease is spreading.
It is only when the affection has passed over the top of the head and
reached the back of the neck, that the sharply defined reddening of
the skin is again to be seen.

Erysipelas of the face, whether fixed or migratory, is not, how-
ever, necessarily so extensive as I have described it. On the
contrary, it is often confined to the cheeks, or even one cheek, or to
the neighbourhood of the forehead, the ear, or the lower jaw. In
some cases no local disease can be detected as the cause of these
circumscribed forms of the affection. But, for the most j)art, they
evidently arise from some local complaint, such as eczema or lupus
of the nose or lips, periostitis, deeply seated abscesses, or caries or
necrosis of the bones. There is also one variety (the Ert/si^pelas
odontalg'icwn) which is set up by caries of the fangs of the teeth,
whue another (the Eri/sipelas otalgicum) is caused by disease of the
external auditory meatus, or the neighbouring parts.

2. Eri/sipelas mammarum. — This is an erysipelatiform dermatitis,
which is generally secondary to abscess of some subcutaneous struc-
ture, especially the mammary gland. Like the affection last de-
scribed, it also may be either fixed or migratory.

3. Erysipelas uinbilici. — This is a not uncommon disease of newly

VARIETIES. 3o7

born cliildren, aiising from^ and being kept up by, suppurative
action occurring at this spot. It, too, may be stationary, or may
spread to adjacent parts,

(4) Eri/sipelas gemtalium. — This disease may be met with in
either sex, and presents the ordinary symptoms, but requires to be
specially distinguished from the acute forms of eczema, which occupy
the same parts. It most commonly appears as a metastatic affection
in t]ic course of one of the exanthemata.

(5) 'Erysipelas extremltatum. — This also is sometimes due to the
formation of metastatic deposits in cases of general pyeemia, and
is sometimes secondary to ulcers, or abscesses seated in the sub-
cutaneous areolar tissue, or to wounds or other injuries. Its symp-
toms differ in wo respect from those which have been described as
belonging to erysipelas in general; and it may either remain con-
fined to the spot originally attacked by it, or become migratory and
spread to the neighbouring parts of the cutaneous surface.

Diagnosis.

It is not possible to draw strictly a line of distinction between
erysipelas and the affections which some have described under the
names of erythema, inflammatory oedema, and idiopathic dermatitis
(using this last term in a sense different from that in which I have
employed it). For, in practice, we see many cases in which these
conditions pass one into another, or are present simultaneously. Yet
we can, in general, state what symptoms are most characteristic of
erysipelas; and, in most instances, we can distinguish these from
those of the other diseases I have named. The most striking charac-
ter of erysipelas is, undoubtedly, besides the reddening and heat of
the part affected, the existence of considerable swelling ; for in the
mere erythemata no great amount of swelling is ever observed,
whereas botli the other symptoms to which I have referred are
present. Again, the course and duration of these diseases are very
different. The erythemata last but a short time, and, when they
subside, leave behind no morbid changes in the skin, being followed
neither by desquamation nor by pigment-deposit. On the other hand,
a much longer jieriod is required for the development and involution

338 ERYSIPELAS.

of erysipelas ; and this disease is, iu every case, followed by desqua-
mation of the cuticle, and by a change in the colour of the skin,
which becomes yellowish or brownish. Moreover, crusts are very fre-
quently formed by the drying-up of the fluid poured out; and,
indeed, other changes in the integument besides these are sometimes
observed. Lastly, in the erythemata either no concomitant symp-
toms of importance are present, or their existence enables us to
determine that the patient is affected in addition with some other
substantive disease ; whereas severe shivering is never absent in cases
of erysipelas, advancing and receding 2^ari passu with the cutane-
ous affection. By the presence of the symptoms last mentioned
Ave can also, in every case, distinguish erysipelas from the local
disease Avhich, as I have stated, some have named an idiopathic
dermatitis.

In acute oedema, on the other hand, although no considerable
amount of heat or redness is present, the skin is tense and swollen in
so marked a degree, and its surface is so smooth and shiny, that this
affection may be distinguished without difficulty from every form of
erysipelas. '\\^hen pressure is applied with the finger to a spot
which is oedematous, a little depression is produced and the part
assumes a paler colour ; and these effects afterwards slowly disappear.
But on the application of pressure in the same way to a region
affected with erysipelas the swelhng is iu no degree lessened, and
the redness vanishes for an instant only, enabling us to see that
the skin lias a yellow^ tinge. (Edema is, indeed, followed by des-
quamation, which continues for some time after this affection has
subsided ; but even then the colour of the skin is not altered, as it is
in erysipelas : nor are any pustules or abscesses ever formed as a
result of the one complaint, although these appearances are com-
monly met with in the other.

Pathological Anatomy.

The morbid changes in the skin which present themselves in ery-
sipelas are essentially the same as in every other form of dermatitis,
and consist in a stasis of the blood and in the formation of inflam-
matory exudation. This exudation is poured out both into the sub-
stance of the cutis, and between it and the epidermis ; and thus we
find a sufficient explanation, not only of the swollen condition of the

PATHOLOGICAL ANATOMY. 339

integument^ but also of the occurrence of vesicles, bullsej and pus-
tules. Moreover, the tissue of the true skin is often reduced into
the smallest possible bulk (wird auf ein Minimum reducirt) by the
amount of exudation which is formed, and the hair-sacs are com-
pressed to such an extent that the hairs fall out when the mflam-
mation has subsided.

According to the investigations of Andral and Gavarret^ the blood
of patients suffering from erysipelas contains au excess of fibrin, but
less than the normal proportion of blood-corpuscles and of fixed
salts. But the results which they obtained were not sufficiently
constant to be of any great scientific value. Analyses of the blood
under any circumstances require to be performed A\äth great care ;
and more than usual accuracy is needed in such a disease as ery-
sipelas, which may arise from such varied causes, both internal and
external to the body.

It is only in those cases in which the eruption did not disappear
before death that the stasis of the blood can be demonstrated in ex-
amining the bodies of those who have died of this disease. The cause
of death is found to be either an anaemia, resulting from the extent
to which the inflammation of the skin had spread, or some patho-
logical change due to the morbid condition of the blood (Blutkrase),
to which the disease itself owes its origin. It will also be readily
understood that exliaustion of the nervous system may give rise to
the fatal termination, particularly when the affection is very exten-
sive. The immediate cause of death is either a congestion and acute
cedema of the brain, or a meningitis, or an hypostatic engorgement of
the lungs ^^itli pulmonary cedema, or, again, an cedema of the glottis
due to the inflammation lia\ing extended to the mucous membrane.
Moreover, pneumonia, pleuritis, pericarditis, or even peritonitis or
enteritis, is sometimes found on post-mortem examination in these
cases. The blood is fluid and of a bright red colour when death
occurs while the disease is at its height ; but if exudation has been
pom'ed out in large cjuantity before the fatal termination, the blood
is found to be in an inspissated condition (im Eindickungszustande).

The causes of erysipelas may, in general, be divided into the
external or local, and the internal. Their action may be intensified

340 ERYSIPELAS.

by a predisposition (Disposition) to the disease^ dependent on tlie
existence of conditions favorable to its development. These pre-
disj)osing causes, also, may either be external to the patient, or have
their seat within his body.

(i) Among the local causes we have to enumerate certain pre-
existing diseases, in which the inflammatory action is liable to extend
to the skin, and so an erysipelas is produced. Under this head
lall—

[a) Various hißammatory affections of deeply seated parts, which
are connected with the skin either by continuity of tissue or by vas-
cular communication. Among these affections may be mentioned
periostitis, caries, phlebitis, arteritis (for instance, the arteritis mnbi-
licalis of infants), lymphangiotis, and adenitis.

{b) Certain diseases in which the cutaneous tissues are exposed
to the local action of pus. The affection due to this action has gene-
rally been included under the name of purulent absorption (Eiterre-
sorption). In reality, hoAvever, it resembles the red ring {areola,
Entzündungshof), which arises when the contents of a vesicle be-
come converted into pus, and which is due to the action of the
puriform fluid. The areola of such a pustule is, in fact, quite
analogous to the more or less extensive erythematous blush which
makes its appearance round any part which is the seat of suppura-
tion or ulceration. For instance, Ave often see erysipelas produced
by an inflammation of the nasal mucous membrane ; and we have
the so-called erysipelas otalgicnm, secondary to ulcerative mflamma-
tion of the external auditory meatus, and the erysipelas genitalium,
which appears in women as a result of diphtheritic or aphthous
affections of the vulva. So also an erysipelatous inflammation of
the skin developes itself round ulcers or wounds when the pus which
they secrete is not alloAved free exit; and the same thing is observed
at the periphery of any pustular eruption (such as eczema or lupus)
Avhen the pus happens to accumulate beneath the crusts. In all
these cases the dermatitis is set up by the local action of pus on the
parts with which it comes in contact.

(2) The internal causes of erysipelas are far from being as "well
known to us as the local causes, of which I have been speaking.
They include, however, certain changes in the blood itself, which are
partially described as hemgp/i logistic, septic, or pyamic. Indeed, a
condition otpycemia — due to an infection of the circulating fluid by the
absorption of pus or some organic matter, or even of tissue-elements

ETIOLOGY. 3il

ill a state of putrefactive fermentation — is probably the fuiidamcntal
cause of erysipelas in most instances, if not in every case. In sup-
port of this opinion, I may refer to direct experiments, in which pus
and various putrid matters have been inoculated from without (as,
for instance, in cases of vaccination with unhealthy lymph), and
to the results of the absorption of certain animal poisons, such as
the contagious principles of -glanders and of the " Milzbrand,^^ the
poison of serpentSj the post-mortem room virus, &c.

Among ihe ßj'edisjoosin^ causes of this complaint are enumerated
arthritis, chlorosis, scrofulosis, and certain diseases ; and, lastly, the
having been before afl'ected with erysipelas.

Dr. Carl Haller, Primararzt in the General Hospital at Vieima,
has shown by statistics,^ based on observations carried on for ten
years in that institution, that this disease is of more frequent occur-
rence during the months of April, May, October^ and November,
than at other times of the year.

It is, moreover, incontestable that at certain periods the foUoAnng
diseases are all unusually common : viz., erysipelas, erythema, herpes
zoster, herpes Iris, furunculi, inflammations of the cellular tissue,
and whitlows (Panaritien) . At these times, also, wounds are apt to
take on an unhealthy action, and are often attended with gangrene or
(liphthentis cutanea. Those who are fond of such expressions may,
if they choose, account for these facts by ascribing them to a genhis
eindemicus, or to a const itiitio eryiipelatosa.

The view held by the older physicians, and even by some of those
of the present day, that sordes gastriccB, catarrhal diseases of the
intestinal canal, and hepatic affections are among the causes of
erysipelas, evidently arose from a mistake. As I have already men-
tioned, a yellow colour is often seen at the edge of the red patches,
and also on the patches themselves, when the redness has been
removed by the application of pressure. But this yellow colour
is due, not to the presence of biliary pigment in the blood, but to
the same cause as the redness, namely, to the colouring matter
of the blood itself. So, also, a furred state of the tongue, a loss
of the natural relish for food, vomiting, diarrhoea, &c., are
not symptoms special to diseases of the digestive tract and the
liver, but, as is well known, may be due to general morbid con-
ditions, affecting perhaps the blood alone, or even to cerebral or

' ' Die Volkskraiikheiteu in ihrer Abhängigkeit von den Witterungsver-
hälluissciV &c., Wien, ISGO.

342 ERYSIPELAS.

nervous complaints. Hence the presence of these symptoms is no
proof whatever that the intestinal canal is primarily diseased.

Lastly^ we are as yet unable to determine whether or not
" catching cold" (Erkältungen) can really give rise to erysipelas.
As is well known, tliis agency has been very greatly abused by
medical men, who have had recoui'se to it as a makeshift when-
ever they have failed to find any direct cause for a disease.

Prognosis.

The prognosis in erysipelas is so far favorable, that a fatal
issue is never produced by the morbid changes in the integument
alone. It is only when the pathological state which caused
the erysipelatous inflammation of the skin gives rise at the same
time to disease of other important organs, that the patient's con-
dition becomes serious, or that there is any danger of the case
terminating fatally. Thus it may be said with truth that no one dies
of eriislpelas. But the visceral affections which may accompany
and result from this complaint often destroy the patient. Among
these affections are, as I have already mentioned, the following : —
Hypersemia et oedema cerebri, meningitis, oedema pulmonum, oedema
glottidis, pneumonia, pleuritis, pericarditis, and peritonitis. More-
over, that form of pysemia which is unattended with any local
changes often leads to a fatal termination in these cases. But an
erysipelas free from all complications invariably ends in the reco-
very of the patient.

Treatment.

From the time of Aetius it was an estabhshed maxim, that
erysipelas should be treated in no other way than by the external
use of dry warmth, and the internal administration of cooling pur-
gatives. But, ill more modern times, remedies of various kinds
have gained acceptance, according to the %äews which have been
entertained concerning the nature of the disease. Thus, the general
treatment has been made to consist in the employment of general
or local bleeding, and in the exhibition of emetics and purgatives,
or of diaphoretic medicines; while the local remedies, used at the
same time, have been more varied still. At one time, cold was em-
ployed; at another time, warmth and moisture; and among the
other applications which have been suggested, are opium, cam-

TREATMENT. 343

phor, collodion, and oil. Some have ascribed specific effects to
inunctions with lard, or to the use of nitrate of silver painted over
the part ; and vesicants, and even the actual cautery, have found
their advocates. Then, the so-called sjiecijic system, introduced by
Hahnemann, came into vogue ; and, without knowing it, those who
practised this method really employed a very simple, and (one may
even say) an expectant treatment, of w^hich the results were not less
favorable, if indeed they were not more favorable, than those pre-
viously obtained.

Priessnitz, again, and his followers advised the application of cold
water both in erysipelas and in every other disease, and have carried
out this treatment with success.

All of these methods have, in fact, been attended with results
which are very much the same. Whichever of them may have been
employed, the majority of the patients have recovered, but some
few have died ; and in each case the per-centage of deaths has been
the same. Since, then, experience does not pronounce in favour
of one rather than another of the various modes of treatment
which have been extolled by different writers, I prefer one which
is simply expectant.

So various, in fact, are the symptoms which are observed in
cases of erysipelas (and these varieties may probably be traced to
differences in tlie cause of the disease), that there cannot, properly
speaking, be any question of a sjpecific treatment. Hence, in ex-
pressing an opinion that the expectant method is the best, I am far
from wishing to exclude the employment of remedies for the relief
of particular symptoms. Indeed, a point on whicli I would parti-
cularly insist is that, in managing a case of erysipelas, we must
always distinguish between the treatment of the cutaneous affection
and that of the various symptoms by which it may be accompanied.
This symptomatic treatment must be based on general principles
now admitted ; and, therefore, no detailed description of it is
required. It is only in considering what remedies should be em-
ployed to counteract the affection itself that I shall base my opinions
directly on the view which I take of the nature of erysipelas, as
being essentially an inflammation of the skin.

When any other part of the body is inflamed, the procedure which
we adopt consists of what is termed the antiphlogistic method (der
antiphlogistische Apparat) ; and when the slcm is the seat of inflam-
mation, this mode of treatment is peculiarly applicable, because we

344 ERYSIPELAS.

are in this instance able to make our remedies act directly on the
region affected. Now^ in speaking of antiphlogistic agents I do not
mean venesection^ leeches^ cupping, scarifications, and the like. All
these I regard as being in this disease superflnous, if not injurious ;
and cold is the only antiphlogistic agent to which I have recourse.
Thus I cover the reddened, hot, and swollen patches of skin with
rags dipped in cold water and afterwards well wrung out; and
upon these, if necessary, I place a caoutchouc bag, or a bladder,
half filled with small pieces of ice. These applications are continued
day and night, uninterruptedly, until the tension, pain, and heat of
the inflamed parts have subsided, which generally occurs within a
period of from two to four days.

I do not find that when cold (Eisumschläge) is employed in this
way, there is any liability for the erysipelas to disappear of a sudden,
or to undergo metastasis to any internal organ. The patients them-
selves speak of this mode of treatment as bemg very agreeable, and as
removing the annoying sensations of tension and heat in the part
affected. In fact, they state that the complaint is relieved, in a
marked degree, by the use of cold applications.

Besides employing cold in the above-described manner, I have
frecpiently used with advantage the blue mercurial ointment, espe-
cially in the migratory form of erysipelas. I have then had the
ointment spread on a piece of linen, and have laid this upon the
inflamed spot, so as to be accurately in contact with every part of
it. Outside the linen I have placed (as usual) compresses first
dipped in water, and upon these, again, a bladder containing ice.
Should the spreading of the disease continue in spite of this treat-
ment, I cover not only the parts recently attacked, but also the
healthy skin beyond, over a space of two fingers^ breadth, witli
linen smeared with mercurial ointment, and outside this apply cold
as before.

At the same time, T never omit to examme carefully the parts in
the immediate neighbourhood of the surface affected with erysipelas,
in order to detect, if possible, its cause. It frequently happens
that this may be recognised in some small pustule placed close by,
or, perhaps, in an eczema (especially an eczema of the nasal fossse),
or in a deeply seated abscess, or a swoUen gland, or some previous
cutaneous affection. When this is the case, a suitable treatment
must, of course, be at once applied to the disease which thus formed
the starting-point of the erysipelas. Above aU, the accumulation of

TREATMENT. 345

pus at this spot must be prevented by the use of emollient cata-
plasms, by rubbing the part with oil, and by the removal of any
crusts which may be formed ; and, in some cases, it is advisable to
destroy tlie purulent focus (den Eiterherd) by the direct apphcation
of nitrate of silver.

When the cold has been employed for some considerable time, it
often happens that the part becomes numb and devoid of feeling ;
in other words, anaesthesia is produced. Under these circum-
stances, the patient is naturally unwilling to continue the cold
applications ; and they should, therefore, be left off for a time, until
the return of heat and pain in the part makes them again acceptable
to him.

The plan of treatment above described is one which I can conscien-
tiously recommend for adoption, in most instances. I can declare that
it is always perfectly harmless, and that it is in the majority of cases
very valuable, from its soothing the patient and relieving the pain
which he suffers. But I must, at the same time, acknowledge that, in
some mild forms of erysipelas, there is no necessity for the application
even of rags dipped in cold water, still less of blue ointment, or
bladders containing ice. In these cases, a purely expectant method,
without the employment of any local remedy, will effect all that is
desired.

As I have already stated, the internal treatment, in cases of
erysipelas, should be purely symptomatic. A'ery often, all that is
necessary is to act upon the imagination of the patient and his
friends. The result will be much the same, whether, on the one
hand, we give the Decoct. Althese with Liq. Amm. Acet. (as some
recommend), or cooling drinks, containing the Acidum Halleri,^ or
dilute phosphoric acid, or lemon juice, or the Potio Riveri ;" or
wdiether, on the other hand, we simply allow our patient to drink
cold w'ater. We should always avoid prescribing energetic remedies,
such äs emetics or purgatives, which, indeed, are admissible only
wdien there is decided constipation, or when the stomach is oxex-
loaded.

1 This is i]iQ Acidum Sidphiricum Älcoholisatum, or the " Hau de Rubel.''' It
is made hy mixing equal parts of strong sulphuric acid {66 degrees) and of
rectified spirit (36 degrees). The alcohol is added gradually to the acid ; tlie
mixture is left for a week, and is then poured oflf into a stoppered vessel.
Jourdan, 'Pharm. Univ.' — [Ed.]

^ This is an effervescing mixture, made, for the most part, with carbonate Ox
potass and citric acid. — [1'^d.]

346 DERMATITIS PHLEGMONOSA.

2. Bermatitls phlegmonosa.
(Deeply seated, plilegmonous symptomatic inflammation of the skin.)

By the term phlegmonouB inflammation of the shin, I understand,
with Rokitansky, an inflammation affecting the whole thickness of
the integument, from the papillae down to the deepest strata of the
cutis, and often involving even the subcutaneous fatty and areolar
tissues. This foi-m of disease is distinguished by the following
characters : — The redness is less bright than in erysipelas, but
cannot be entirely obliterated by the pressure of the finger. The
skin, after the disappearance of the redness, displays a deep yellow
colour. The swelling in this affection is remarkable not so much
for its extent as for the great degree of firmness and induration
presented by the cutaneous tissues. The Dermatitis phlegmonosa
generally runs an acute course. It docs not often subside and
terminate by the absorption of the effused matters : on the contrary,
it results for the most part in the formation of abscesses, or the
destruction of the part by sloughing. It may, however, present
itself in a chronic form, and may develope itself from an acute
phlegmon (aus der acuten Phlegmone), or be secondary to various
cutaneous affections, among which are eczema and prurigo. More-
over, it may appear as a result of disease of the cutaneous veins,
being then the starting-point of the so-called varicose ulcers.

Phlegmonous inflammation in the acute form sometimes affects
small portions of the skin only, in which case the morbid appear-
ances produced by it are termed fnrunciiU. In other instances, it
attacks large tracts of the skin, constituting the disease kno'mi by
surgeons under the name of pseudo-erysipelas (Rose mit Gangrän,
Waltman — Necrose des Bindegewebes).

The symptoms of both the cii'c um scribed and the diffuse varieties
of the acute phlegmonous dermatitis may be included under the
following description : — The first symptoms of the disease are
generally subjective sensations, the patient complaining of pain in
some region of the body, increased by the application of pressure.
At this time no change is to be seen in the colour of the spot
affected, but some part of the skin, of greater or less extent, is

DERMATITIS PHLEGMONOSA. 347

felt to be indurated, the hardness being sometimes cii'cumscribed,
sometimes diffused. A day later, a bright-red blush begins to
be perceptible, appearing, for the most part, first on the summit of
the elevation felt by the touch. This blush at once spreads not
only over the part which is indurated, but also beyond it ; and the
swelling, redness, and pain now increase from hour to hour. The
subsequent coui'se of the disease, however, is not in all cases the
same. Sometimes, after the lapse of a shorter or longer time, according
to the extent and severity of the affection, the redness and the indu-
ration subside ; the pain then diminishes, and, at length, all that
there is to show that a dermatitis has existed is that the epidermis
peels off in greater quantity. In other cases, and far more fi'e-
quently, fluctuation is after a time perceptible at the seat of the
disease, and becomes more and more distinct, until, at length, the
pus which has accumulated is enabled to escape, by the skin over
it becoming softened, or sloughing. The contents of the abscess
having in this way been discharged, its interior is exposed to view,
and we then see a white, or whitish-yellow, firmly adherent mass,
formed of dead connective tissue. This slough is of greater or less
size, according to the extent of the original inflammation. It some-
times forms a continuous mass, and may then be of large size;
while, in other instances, there are several distinct sloughs. These
white or wliitish -yellow masses of areolar tissue afterwards become
detached from their bed, and are extruded. As soon as this has
occurred, the amount of pus formed begins gradually to diminish,
the walls of the abscess fall in, its base becomes covered with
healthy granulations, and the part heals. A cicatrix of greater or
less size is always left in these cases.

The pathological process I have been describing, when confined
to a small spot, produces the affection which is termed by Fuchs the
Thy ma (Entzündungsgeschwulst of certain writers), but wliich is
known to most medical men under the name of the Furunculus
(Eurunkel, boil) . This last term is the one to which I give the pre-
ference, and I do not admit the existence of any distinction between
the Entzündungsgeschwulst (inflammatory tumour) and the fiu'un-
culus. I shall give in detail my reasons for holding this opinion,
when I come to discuss the etiology of the phlegmonous inflamma-
tions of the skin.

The distinctions between the various forms of furunculi to which
Alibert and others have drawn attention are also of very httle im-

31S DERMATITIS PHLEGMONOSA.

portance. As I have already stated^ the phlegmonous inflammation
of the skin is sometimes confined to a small spot not bigger than a
lentil or bean, while in other instances the part affected is as large
as a man's fist ; but there is no essential difference in the nature or
course of the disease in the two cases. There is, therefore, no
real necessity for distinguishing between a '' follicular furunculus''
(roUicular-Furnnkel) and a " furunculus of the areolar tissue" (Zell-
gewebs-Purunkel), merely on account of their difference in size.
Agam, different epithets have been given to furunculi, according to
the way in which the pus is discharged. If the roof of the abscess
is penetrated by its purulent contents at a single point, the affection
is termed a F. simplex j if at several spots, it receives the name of
F. vespajus ; w^hüe, if the pus is allowed to escape only through a
small fissure, it is called a F. j^anidatus. But these differences are
by no means so important as to render it necessary that divisions of
the furunculns should be founded upon them.

The following, then, is an adequate definition of this affection : —
A furunculus is a circumscribed phlegmonous inflammation of the
skin, terminating in suppui-ation and in the formation of an abscess,
but not in gangrene of the roof of this abscess.

When gangrene of the inflamed part of tlie skin occurs, we have
to deal, not with Vifurunculus, but with an anthrax. Thus the anthrax
or carbuncle is a swelling of a furuncular character, but presenting
the essential peculiarity that its roof undergoes mortification. The
appearances in this aftection are not always the same. Sometimes
the surface assumes a bluish-bUick colour, and a bleb is formed by
the elevation of the epidermis ; or the integument is penetrated at
several distinct points by the sloughing connective tissue, so that,
when this has been extruded, the part affected presents a sieve-
like api)earance. But, in other instances, the whole skin, including
both the derma and the cuticle, softens down into a discoloured pulp ;
or, lastly, the integument and the gangrenous connective tissue
beneath dry up together into an eschar of a brown or even a black
colour, and as hard as leather.

The further changes in an anthrax consist in the detachment of
the different sloughs of connective tissue, exactly as has been de-
scribed in the case of the fui'unculus. The cavity which is thus
produced is more or less extensive according to the size of the
sloughs ; it becomes filled up by granulations, and heals, leaving
for the most part a very distinct cicatrix.

DERMATITIS PHLEGMONOSA, 349

Such are the local changes which occur on the cutaneous surface
in these affections. But^ besides these, general symptoms are in
most instances present. These are most marked in cases of car-
buncle, but they may be observed even in furunculosis, especially when
several boils appear simultaneously. Thus, severe febrile disturb-
ance, with shivering, often precedes an attack of one of these forms of
phlegmonous dermatitis, or sets in during its course ; and among the
other concomitant symptoms may be mentioned headache, loss of
appetite, a furred tongue, dryness of the mouth, and nausea. When
the progress of the case is favorable, these symptoms subside as soon
as the gangrene has reached its limits, and from this time the local
changes form the only mdications of the disease. It is, however, to
be stated that these affections sometimes have a fatal issue. This
occurs, for instance, when the gangrenous action does not become
limited, but goes on spreadmg from point to pomt. Moreover, even
when the extension of the sloughing has ceased, the death of the
patient may be caused by exhausting suppuration, or may result
from purulent absorption and pysemia, or be due to the aggravation
of the general morbid condition or dyscrasia, which itself gave rise
to the formation of the antlu'ax or furunculi. In these cases
pustules and furuncles of various sizes are often at first the only
symptoms, and for a considerable time nothing occurs beyond the
repeated formation of boils. But sometimes, even from the com-
mencement of the patient's illness, small anthraces appear, which
take the ordinary course till at last a large carbuncle arises at some
part of the body and puts an end to his existence.

These forms of phlegmonous inflammation of the skin, described
as furunculi and anthraces, may be either sporadic or endemic, or
even, according to Fuchs and other writers, epidemic.

Eurunculi sometimes occur, sporadicaUi/ , in persons who are in
other respects healthy, concomitant symptoms being then alto-
gether absent. In other cases they are secondary to some one
of the chronic dermatoses attended with itching (such as eczema,
scabies, or prurigo), or arise from the initation produced hj pediculi
vestimentorum. Again, they often occur singly, the one which first
appears being followed by no others ; but sometimes several of them
make their appearance together, and fresh ones keep breaking out
for a very considerable time.

Thus, then, both the furunculi and the anthraces are naturally
divided mto two groups — the IdiojuUhic and the symptomatic.

350 DERMATITIS PHLEGMONOSA.

The idiopathic phlegmonous mflammation of the skm (phyma) may
be set up by mechanical injury, or by irritation of any kind, affecting
the skin. I -would here specially refer to the furunculi caused by
the repeated application to the cutaneous surface of cold water,
which, as employed by the hydropaths, is an irritant to the skin.
As I have already stated, similar affections appear in the train of
certain cutaneous diseases attended with itcliing. In fact, boils very
frecjuently accompany those morbid changes in the skm which are
caused solely and entirely by the patient repeatedly scratching him-
self, and are not at all due to any dyscrasia. Thus Ave often see
furunculi in persons who are merely affected with body -lice, and who
are constantly compelled to scratch themselves by the irritation set
up by these animals, and by the sensations of itching which are thus
produced. The same thing is observed in scabies, which no one,
surely, at the present day, will suppose to be caused by a dyscrasia.
Under these circumstances, we may venture to infer that furunculi
arise from the direct action of local irritants upon the skin, and not
from any general internal cause to be looked for in an altered state
of the blood. Hence that view is clearly inadmissible which ascribes
to these furuncular affections a critical character, and they may,
■snth perfect correctness, be regarded as idiopathic.

Every one, however, knows that boils are also apt to arise in
greater or less numbers without the skin having been in any A\ay
irritated, and that the complaint may then become chronic from the
repeated formation of fresh boils. Such symptomatic furunculi are
generally attended with symptoms of a different kind, and particu-
larly with yelloAvness of the skin, anorexia, depression, lassitude,
malaise, and sometimes even A\ith fever and loss of flesh. Hence
these affections have rather to be regarded as being expressions of a
constitutional disorder, to which the name oi furunculosis may be
given with advantage, for the use of this term serves to distinguish
the cases in Avhich repeated outbreaks of furunculi occur from
those in Avhich their appearance is merely accidental.

With these constitutional forms of furunculosis may be associated
certain diseases which are caused by animal contagia, giving rise
to phlegmonous inflammation of the skin. These diseases are —

GLANDERS. 351

I. Glanders. II. The pitstular affection produced by the cadaveric
poison. III. The pusiula maligna.

1. The disease known as (/landers (Rotzkrankheit, Mahasmus of
Fuchs, Morveet farcin of Eayer) presents the following characters : —
The first symptoms of it are pains in the joints and shivering, which
are followed either by an eruption of pustules alone, or, in addition,
by the formation of certain hard lumps resembling furunculi, isolated
from one another and of a red colour. Moreover — sometimes in
association with these cutaneous affections, sometimes apart from
them — patches of the skin are found to be of a variegated blue and
yellow hue, and to have become indurated and the seat of extensive
heemorrhage ; and large deposits of inflammatory exudation in the
tissues of the integument are formed at the same time. These
morbid changes are all pretty rapidly developed, and are accom-
panied by continued febrile disturbance, or even by cerebral symp-
toms. Pneumonia, likewise, sometimes arises in the course of this
disease, which, almost without exception, terminates fatally.

In some instances, glanders, at its commencement, resembles small-
pox ; and it often happens that a patient sufifering from the former
complaint is at first supposed to be affected with the latter; the
eruptions of the two diseases (in reality very similar) being con-
founded by medical men who have had but little experience, or have
made only a hasty examination of the case. Moreover, pain in the
back and cerebral symptoms may belong to either of these complaints.
But the careful observer cannot mistake glanders for smallpox, on
account of the presence of the more extensive circumscribed patches
(the seat of inflammatory exudation due to the phlegmonous derma-
titis), and of the widely difiused hsemorrhage into the skin, giving
certain parts of the surface a chameleon-like play of colours.

Equally different are the appearances found in the dead body after
these diseases. As is well known, the pustules of variola remain
after death, appearing flattened, and being imbedded in the substance
of the cutis, filled with a whitish-yellow- fluids and evenly distributed
over the whole surface of the body; and the skin between these pus-
tules is found to be in a healthy state. Now, in glanders, the hard,
yellow or livid patches above described remain unaltered in the dead
body, and present the same appearance as during the life of the
patient. But generally no pustules are to be seen, those previously
observed having by this time subsided, or having been destroyed.

352 DERMATITIS PHLEUMüNUSA.

Large livid spots^ however, appear isooii after death in cases of
glanders, and, indeed, after all diseases in which decomposition sets
in early. When the patches which are the seat of infiltration are
cut into, they are found to be filled with a large quantity of black
blood. The mucous membranes of the throat, the nasal passages,
and the larynx are also invariably afl'ected in this disease.

It was at« one time believed that glanders developes itself in
human beings only when they have been bitten by glandered horses.
But, in the course of the last few years, it has been proved beyond a
doubt that it is quite possible for a man to be infected with this
complaint by merely liAOng and sleeping in a stable containing horses
affected with it, or by having to do with the carcasses of dis-
eased animals. Indeed, it appears that glanders is so communicated
in most cases, and that it comparatively seldom arises from a bite.

However, though there can be no question that this disease is
caused solely by the transference of the special contagions princi])le
from an animal to man, yet it is not, in all cases, possible to ascer-
tain exactly the way in which infection occurred ; and the proof be-
comes all the more difficult, because (as is well known) glanders
cannot be further propagated in the human subject, and never passes
from one human being to another.

II. Another disease of a similar kind is one to which certain
persons are especially exposed, including anatomists, surgeons, veteri-
narians, post-mortem room assistants, butchers, flayers, and others.
It is caused by the penetration of decomposing animal matters
into wounds, or even into the iminjured skin (particularly of the
hands), leading to the development of various cutaneous affections
similar to those just described. These affections are spoken of by
German writers under the name of Leicheninfections-Pusteln.^

In some cases this disease consists merely in the formation, on
the surface of the hands, of a few pustules 'or buUse filled with pus) of
the size of lentils. These pustules are seated exactly round the
mouths of hair-sacs, and each of them is therefore perforated by a
hair.

They sometimes undergo involution, and lead to no further ill-
effects. But, in some instances, redness and swelling quickly spread

' Dr. Wilks has proposed the name of Verruca necrogeaica for anotlier
cutaneous disease arising from this cause. Perhaps the term "Necrogenic
Pustule" might be applied to tlie affection wliicli is described in the text, and
which appears to have received no special name in this country. — [Ed.]

IsECROGENlC PUSTULE. 353

from these pustules to the adjacent parts of the cutaneous surface,
foUo^nug the course of the vessels : in other words, the characteristic
signs of absorbent inflammation may at once be recognised. When
this occurs, pustules and absce'Sses not infrequently form along
the track of the inflamed lymphatics ; and the glands, in which these
terminate, become swollen and painful, and suppurate. Moreover,
the neighbouring connective tissue may also be involved in these
morbid processes, and a very extensive loss of substance may be
produced by its sloughing; so that a condition dangerous to the
patient^s life may even be set up by the sympathy of the organism
in general.

From the nature of these inflammations of the skin set up by
animal poisons, it is easy to perceive that besides the symptoms
already mentioned many others may present themselves of which
no precise account can be given, and wdiich bear only a general
resemblance to those described as occurring in furunculosis and in
glanders. Thus, we may have to deal with the most simple circum-
scribed dermatitis, or with a very extensive erysipelatous swelling :
small points of suppuration may alone present themselves, or very
wide excavations may be formed, and large quantities of un-
healthy pus may be discharged; there may be slight exfoliation
from the surfaces of the bones, or whole phalanges may undergo
necrosis ; and between these extreme forms numerous intermediate
conditions are met with, which it is impossible and unnecessary to
describe in detail : for all that is requhed is that we should recog-
nise the cmise of the malady, and keep its stature constantly before
our eyes.

Experience teaches that for the absorption of the animal poisons
which geuerate these diseases, it is not always necessary that the
epidermis should be injured. I have, unfortunately, had abundant
opportunity (in both the school of pathological anatomy and the
veterinary institution, and also in the case of operating surgeons
when practising on the dead body) of satisfying myself that these
aff'ections not rarely arise independently of any previous wound,
although, no doubt, they are in many instances preceded by some
injury. Thus, the absorption of the cadaveric poison has often
taken place in persons suffering from eczema or some other skin
disease; and it is especially apt to occur when those who make
autopsies, or perform operations on the dead subject, are careless,

354 DERMATITIS PHLEGMONOSA.

neglect to wash frequently, and allow the fluids from the dead body
to dry on their hands.

III. The affection known under the name of Pustula maligna
differs in no respect from those which I have been describing, except
that, when this disease commences, a single bleb alone exists, which
is filled with a serous fluid, and of which the base is the seat of
hsemorrhage. This bleb appears in most cases on the back of the
hand, or at any rate on some part of the upper limb, and forms a
centre from which redness and inflammation extend to the adjacent
parts of the cutaneous surface. Next, absorbent inflammation arises,
and the glands become swollen. The spot originally affected then
becomes gangrenous, the gangrene sometimes remaining circum-
scribed, whereas in other instances it spreads to the neighbouring
textures, destroying the muscles and tendons as well as the skin
over a more or less extensive area. Even in favorable cases in which,
instead of the disease terminating fatally, the gangrenous action
ceases to spread, and the sloughs become detached, profound cica-
trices are always left when healing occurs.

I have still to mention certain endemic complaints in which
appearances resembhng furuncles and anthraces present themselves,
and which have been described under the names of Anthrax malignus
Sibiriens, Esthonicus, Bothnicus , Hungaricus ; Fyrophlijctis endemica;
Bouton (VAlep, &c. But, as I possess no knowledge based on my
own observation of these diseases, I Avill simply refer the reader
to the works or journals in which accounts of them are given.
See H. Fuchs, ' Die krankhaften Veränderungen der allgemeinen
Decke,' Göttingen, 1840, p. 292. Rat/er, 'Traite theorique et
pratique des Maladies de la Peau,' Paris, 1835, 2nde edition,
t. iii, p. 844. Älibert, " Sur la Pyrophlyctide endemique,'" ' Eevue
Medicale,' 1829, p. 62. P runer, 'Die Krankheiten des Orientes,
&c.,' Erlangen, 1847, p. 144. Pigler, 'Die Tilrkei und deren
Bewohner,' Wien, 1852, B. ii, p. 68.

See also the'Gaz. Medicale,' 1854, t. ix, No. 14, pp. 200, 228,
252. ' Memoire sur le Bouton d'Alep,' par le Dr. Ä. Wille77iin.
Polah (Leibarzt des Schahs von Persien) " offenes Sendschreiben
an Prof. Hebra in Betreff' des Bouton d'Alep,'"" in der ' Wiener
Allg. Med. Zeitimg,' j86o, No. 48.

TREATMENT. 355

Treatment.

The Dermatitis phlegmonosa presents two distinct indications
for treatment. In the first place^ we must aim at counteracting
the cause of the inflammatory affection of the skin, whether this
cause be a constitutional dyscrasia or merely a local disturbance.
In the second place, we must endeavour to restore to their
normal condition as quickly, and -wiXh. as little loss of substance as
possible, those parts of the integument which are the seat of the
morbid changes.

The first indication would be satisfied by the administration of
any remedies which should be slio^Mi by experience to have the
power of preventing the occurrence of these diseases, or even of
checking the tendency to relapse. The second object is best attained
by the use of certain well-kno^\'n local applications.

I "vnll begin by speaking of these : and I have, in the first place,
to remark that it must always be our primary object to limit the
inflammatory process as much as possible, and to reduce the tension
and dragging to which the soft parts are subjected ; and, therefore,
that an antiphlogistic treatment is suited to these cases.

Thus, I apply to furunculi, according to their number and size,
and the degree of pain caused by them, either compresses first
dipped in cold water, or bladders fiUed with ice, or even freezing
mixtures consisting of two parts of ice and one of salt.^

' A freezing mixture, by which a temperature as low as 3° Fahr, is reached,
may be made from finely powdered ice and common salt in the proportions
stated above, by mixing them together rapidly in a glazed earthen vessel. The
mixture should be placed in a muslin bag, kept open by means of a ring, so
that the water which forms may at once flow off, and that the cold may be un-
interruptedly maintained. It is to be applied to the surface of the part
affected for about ten minutes, or at any rate until the skin shall have
become white, hard, and nearly painless. Another plan is to touch the part
with the bag containing the freezing mixture every second until the desired effect
is produced. When this has occurred, compresses, previously dipped in ice-
cold water, are to be laid over tiie boil. This mode of treatment is applicable
to all the other forms of phlegmonous inflammation of the skin as well as to
furunculi, and both in their early stages and after pus has been formed. More-
over, in the case of very sensitive persons it may be used to produce local

356 DERMATITIS PHLEGMONOSA.

It is true that we cannot always, by tlie application of cold, pre-
vent pus being formed ; but its amount is at any rate reduced to a
minimum, the pain is much diminished, and the termination of the
complaint is hastened.

This mode of treatment may likewise be used in cases of car-
buncle in its early stage, but the cold must in this aifection be
appHed only so long as it is not disagreeable to the patient. More-
over, the gangrenous roof, as well as the areolar tissue beneath
(which is traversed by numerous points of suppui'ation) , should
be divided by a single incision, or by crucial incisions, or by several
cuts in different directions, according to circumstances.

Those Avho are accustomed to the usual practice of treating boils
and carbuncles from the first by means of warm fomentations and
poultices, will, perhaps, refuse their assent to my antiphlogistic
method until they have tried it either on themselves or on intelligent
patients. A particularly favorable opportunity for trying it pre-
sents itself in the case of persons who have previously been affected
with boils, for which they were treated on the older plan, Tor the
sake of comparison, I have often employed both methods simulta-
neously for patients suffering from several furunculi, and I have
always been told that they preferred the application of cold, and
found it more agreeable ; and the same conclusion is favoured by
the limitation of the inflammatory process, and by the more rapid
course of the disease, observed when this treatment is adopted.

On such principles I have for several years endeavoured to
control all these diseases, including the more widely diffused phleg-
monous inflammations, and even the malignant pustule, the affec-
tion produced by the virus of glanders, and that due to the cadaveric
poison. But it must be borne in mind that I do not promise
that the application of cold will do any good in these cases beyond
limiting the inflammatory action in the part affected. I am per-
fectly well aware that it has no power to remove the cause of the
complaint.

For instance, in furnnculosis, when fresh boils are continually
making their appearance, we can alleviate the local symptoms by
this mode of treatment ; but we are not able, by means of it, to pre-
vent the formation of new furunculi at other points. I must, for my

anaesthesia when an abscess requires to be opened, for it deprives tlie skin of
sensation so completely tbat no particular pain is caused % the puncture, or
even by the unpleasant process of pressing out the slouglis.

TREATMENT. 357

own part, confess that, although in many of these cases I have tried
all kinds of remedies, I have not as yet succeeded in finding one
which has the po^^■er of checking the recurrence of the affections of
which I am now speaking.

Among the medicines which have been vaunted as possessing this
power, are the vegetable and mineral purgatives, the so-called
Ilamaio-catJiartica (as, for instance, the decoction of sarsaparilla), and
the tonics and Antidyscmsica (such as quinine) . But, in most cases,
we find ourselves disappointed in our expectations from these
drugs, and we shall do well, instead of placing much reliance upon
them, to subject the patient to a thorough examination for the
purpose of ascertaining whether some other morbid condition may
not be present, as well as the tendency to the formation of furun-
culi.

I take this opportunity of agam insisting on the fact that furun-
culosis often occurs in those who suffer from disorders of the diges-
tion, and that it is also common in those who live in badly venti-
lated rooms. If, then, the patient is affected with eructations,
heartburn, and other symptoms of dyspepsia, it must be our first
endeavour to remove these symptoms by antacid or bitter remedies,
such as the Trifolium Fibrinuin, the Tinct. Nucis Vomica, or the
sulphate of zinc ; after which the formation of furunculi will cease
spontaneously. The plan which I have found most successful is
to give waters charged wdth carbonic acid (such as ordinary soda-
water), or those which contain small quantities of sulphate of soda,
as, for example, the waters of Marienbad, Franzensbad, or Carls-
bad. Indeed, it is very advisable to send patients affected with
chronic furunculosis to one or other of these spas ; for it is im-
portant that these persons should be kept in a fresh, healthy air ; and
at such places they are at the same time withdrawn from their
ordinary occupations, and are compelled to change their mode of
life.

Medical men are in the habit of recommending baths to be taken
in these cases ; but I have learnt by experience that neither warm
nor cold baths should be employed, except with caution and at con-
siderable intervals. Indeed, every kind of local irritation of the
skin should be avoided : an irritant w^iich, in a healthy subject, would
excite only a trifling eruption of sudamina, or a slight eczema, may
be the cause of boils in a person Avho is liable to them. Against
the use of vapour baths, or strong douche baths, and also against

358 DERMATITIS PPILEGMONOSA.

the practice of sliampooing, I would give a special warning, for
all these are very apt to give rise to furunculi.

Again, I must caution my professional brethren against applying
ectrotic agents in the local affections caused by inoculation with the
cadaveric poison, the virus of glanders, or decomposing animal
substances. In these cases it is too late to cut short the disease by
destroying the original seat of infection and so eliminating tlie
poison; and, therefore, the effect of applying caustics is not to
diminish the duration of the complaintj but merely to increase the
pain suffered by the patient.

CHAPTER XV.

THE PHLYCT^NOSES.

(CLASS IV.— ACUTE, NON-CONTAGIOUS, EXUDATIVE
DERMATOSES.)

I. HERPES.

In the attempt to give an liistorical account of Herpes (in the
sense in which Willan used this term, and in which it is at the
present day generally employed), we meet with almost insurmountable
diificulties. 'Fov in ancient times the Avord 'ipirriQ was used to
designate affections of various kinds, differing altogether from those
which are now known under that name. Thus Hippocrates/ -with-
out admitting the Herpetes as distinct diseases, describes them
simply as critical exanthemata, which purify the body, and of which
the distinguishing characters are, that they are superficial, and that
they spread towards the periphery. Celsus^ mentions Herpes under
the head of örjptwjua, but gives no definition of it. The following
section of his work, that which treats of Ipiis sacer, is generally
supposed to refer to Zoster; but there is scarcely any ground for
this idea, except the statement, '^fit maxime in pectore, aut
lateribus.''^ Scribonius Largus^ (4<3 a.d.) repeatedly employs the
word Zona to designate the tQir^g of the Greeks. His contem-
porary Plinius* understands by Zona an acute cutaneous affection,
attended with the formation of bullae, occupying chiefly the loins
and the abdomen, but met with also on every other part of the body.
He further describes it as confined to one half of the trunk, and
as being fatal when it completely surrounds the patient^s body.

Galen^ applies the word Herpes to those cutaneous ulcers of which

^ De Affect, liber, sect, v, Epidem. 3, sect. 3.

* Liber v, cap. xxviii, 3.

2 • De Comp. Med.,' 62, 63, lib. iii.

* 'Hist. Nat.,' lib. xxvi, cap. 11.

* Comra. i in Aphor. 55, sect. 6.

S60 HERPES.

the destructive action is limited to the surface. He divides the affection
into three species (Jipirrig Keyx^piag, IffOioixevoQ, and (jAvKTaivivdr^g).
The first of these (the Herj)es miliaris) is the only one which bears
even a distant resemblance to our Herpes, being attended with a
pustular eruption. That Galen himself was at a loss in the diagnosis
of this affection, is evident from another passage (' Meth. Med./ lib.
iv), where he says, "Herpes non semper ulcus est.^'

These definitions of the Greek and Eoman writers prevailed for
many centuries ; and they were accepted by the Arabian physicians
Ehazes and Avicenna, who admitted two species of Herpes, the H.
miliaris and the H. corrosiva s. formica.

Actuarius^ ascribes both Avords Herpes and Ignis to a similar
origin. He says — " Herpes dicitur eo quod videatur to-rreiv (quod
est serpere per summam cutem), modo banc ejus partem, modo
proximam occupans, quod semper, priore sanata, propinqua ejus
vitium 'excipiat : non secus quam ignis, qui proxima quaeque de-
pascitur, ubi ea quse prius accensa erant, deficiente jam materia
idonea, prius quoque extinguuntur."

Of the writers of the middle ages I must quote Gorrseus,^ who
mentions Zoster as a species of Herpes, and says — " est autem zona
ignis sacri species, qua medium ambit cingitque. Dicitur alio nomine
ZojcTTiip." On the other hand, his contemporary Fernelius'^ applies
the term Herpes miliaris to an eruption consisting of papules and
pustules ; while he speaks of a Herpes exedens as giving rise to
ulcers. Thus, in determining and defining the disease, he starts
from an entirely different point of view. Some of the writers of the
seventeenth century (Mercurialis, Sennertus) make no mention of
the word Herpes, and do not even describe the affection under any
other name. The definition given by Lorry ^ in the eighteenth
century is the first which corresponds with our conception of
Herpes. After alluding in condemnatory terms to the ancient
practice of including under the name of Herpes both chronic
spreading ulcers and acute inflammatory affections of the skin^ he
defines it in the following words :

" Solitaria vidgo nascitur una herpetis miliaris areola, cute
creteroquin Integra, limbo rubello distincta. Pustulae emicant vulgo

» T. 1283, 'Metb. Med./ lib. ii, cap. 12.
- 'Def. Medic.,' lib. iv, Francof., 1578, p. 156.
^ 'Uuiversa Mediciua,' Trancof., 1592, p. 341. '
* ' Tract de Morbis Cutaneis/ p. 294.

HISTORICAL ACCOUNT. 361

sero repletee sub ipsa epidermide aggregatim compositse, interstitia
replent lemse epidermidis qua? areolam faciimt asperam. Inest
major quam pro malo exoriri debere videretur cruciatus, sed mox et
paucarum horarum intervallo subnascitur altera pustularum agglo-
meratio, quam alise mox confertim adnatee per plurium dierum
spatium excipiunt."

Plenck^ gives a very different description of Herpes, which he
defines as follows: — '^Est papularum chronicarum ichoroso-squamo-
sarum semper ulterius serpentiura agmen." He admits six species
of his Herpes or Serpigo : H. simplex (prurigo ?) ; H. exedens
(lupus ?) ; H. miliaris (acne ?) ; H. 2^ustulosus (impetigo ?) ; H.
syphiliticus ; and K. spurnis (artificial eczema ?) : and he also
mentions a H. perisceles, a H. collaris, a H. cerdomim, and a H.
a iadu toxicodendri. Thus he collects together chronic skin aflFec-
tions which are entirely different, and arbitrarily tickets them as
species of his genus Herpes. He mentions Zona or Zoster in his first
class of Maculae in the following words : — " Sunt vesiculse pisi-
formes discretse, atrorubrge, non raro confluentes, intense prurientes
et dolorificae, quae instar zonre sen cinguli ad manus latitudinem pectus
vel aliam partem circumdant."

This very accurate definition of Zoster was extended by Willan,
mutatis mutandis, to a large number of aff'ections of the skin. He
found that a painful eruption, running an acute course, and consist-
ing of vesicles the size of peas, occurs not only in Zoster, but
also on the face (especially on the red part of the lipsj, and
on the prepuce and genital organs; and, further, that the limbs,
and even the trunk, may be the seat of vesicles collected in groups
having a peculiar circular form. Hence "Willan, and Bateman
who completed his work, distinguished the following species of
Herpes: — i. H. pJd^ctcenodes ; 2. IL Zoster; 3. H. circinatus ;
4. H. labialis ; 5. H. jorcBputialis ; 6. //. Iris. The descriptions
given by these Maiters of the varieties of the disease caused the
previous vague and inaccurate definitions of it to be set aside ; and
Herpes was created into a genus, divided into species.

Some of these species, such as the H. labialis and H. Zoster, had
indeed been mentioned in older writings. But others, and parti-
cularly the H. circinatus et Iris, seem to have been first esta-
blished as special forms of disease by the observations of Willan.
At any rate, I have been unable to find in any previous work either

^ Loc. cit., p. 61.

362 HERPES.

a description or a representation of this affection. It may, therefore,
be justly said that Willan first placed the definition of Herpes on a
solid foundation, by confining the use of the -word to a parti-
cular acute affection running a typical coiu'se.

The contemporaries of Willan and subsequent writers have gene-
rally followed him in his definition of Herpes ; but there have been
some who have contended against this view, among whom Alibert
in particular requii'es mention. This dermatologist, in each of his
two systems, made of the so-called " Tlechtenübel " a special genus, to
which he gave the name of Dartres. In his earlier classification this
forms the third class of cutaneous diseases, and includes seven species.
These are — (i) the H. fmfuraceus, consisting of two varieties — the
H.f. voUtans, and the H. f. circinatus ; (2) the //. squamosus,
which is further subdivided into four varieties — the //. s. mad'ulans,
the H. s. orbicularis, the H. s. cenirifur/us, and the H. s. lichenoides.
(These affections all correspond more or less closely to the modern
definition of eczema.) (3) the II. crustaceus, including the H. c.
flavescens, the K. c. procumhens, and the K. c. musciformis. (These
belong partly to the Eczemata, partly to the so-called Impetigines.)
(4) The H. exedens, which is again divided into the H. e. idiopathi-
cus, the H. e. scropJmlosus , and the //. e. sijphiliiicus. (These
either belong to lupus or are syphilitic affections.) (5) The H.
ptiistulosus, including mentagra and gutta rosea, and also comedones
and acne, which are described as the H. p. miliaris, and the H. p.
disseminatus ; (6) the //. phlijctanoides, under which head he
speaks of a K. p. confluens, a rare and altogether unknown skin
affection, and also a //. p. zoniformis, Avhicli appears to be that
which we know as Zona or Zoster ; (7) the H. eri/themoides, including
a H. e. urticatus, which we ought perhaps to regard as correspond-
ing to the ordinary forms of erythema, or to the E. papulatum and
to Urticaria.

It will at first sight be evident to every one who has the least
acquaintance with dermatology, that Alibert was at the pains to
collect together a number of distinct diseases, acute and chronic,
local and general, idiopathic and constitutional, placing them
in one class under the name of Herpes. This classification intro-
duced fresh confusion into the diagnosis of cutaneous affections,
instead of making it clearer.

In the later system of Alibert, the '^ Dartres" or Herpetes " con-
stituted the fourth group. This also included a smaller number of

HISTORICAL ACCOUNT. 363

diseases, for it was made to consist of four subdivisions^ of which one
only received the name of Herpes [Dartres ordinaires of the French) .
This, however, was further divided into the H.furfuraceus (inchiding
the //. volaficiis and H. circinaius, the last being synonymous witli
the English " ringworm ^^ and the German//, tonsurans), and the
//. squamosus (made up of the H. madidans, orhiciolaris, centrifugus,
and lichenoides) . Thus he endeavoured to set aside altogether the de-
finition of Herpes which had recently been brought forward by
Willan.

Ahbert, indeed, was particularly strenuous in his opposition to
Willan's use of the term Herpes. He accused the EngKsh derma-
tologist of having taken away its old and given it a new meaning ; a
change in which he could see no advantage, and which he charac-
terised as unfortunate. But most of his contemporaries and suc-
cessors adhered to Willan's definition, and Alibert was soon without
any followers in his use of this word.

To the affections called by Willan the II. phlijctanodes, circinatzts,
lahiaJis, ^xAprapntialis, Alibert gave the name of Olophli/ctis. He
dismissed them summarily as forms of eczema. Thus he described
an OlopJdi/ctis miliaris, an affection of an annular character, appear-
ing on the trunk and limbs, but having no very definite seat. This,
according to Ahbert, corresponds to the II. circinatus and Iris of
Willan and Bateman. He also mentioned an 0. volatila, synonymous
with \\\Q few de dents, few volage des enfant s, with the ignis sylves-
tris, and with the Stroplndtis volaticus of Willan; an 0. prolahialis
and an 0. progenitalis, which appear to be equivalent to the Herpes
labialis and //. praputialis of Willan ; and, lastly, an 0. hjdroica,
which answers in part to the hydroa of the Greek writers, in part to
the affection kno\\ii by the name of sudamina.

As I have already stated, Alibert's classification was not even
accepted in his own country, either by his contemporaries or by the
writers who immediately succeeded him. The use of the word
Herpes, introduced by Willan, was adopted even by Biett, and has
been since followed by Rayer, Cazenave, Schedel, Gibert, Chausit,
Duchesne-Duparc, in France; by Plumbe, A. T. Thomson, Er.
Wilson, Jon. Green, Eox, and Hillier, in England; and lastly, by
Eiecke, Simon, and myself, in Germany.

A few, however, of the earlier and also of more modern derma-
tologists have expressed their dissent from the nomenclature of

36i HERPES.

Willan, and have either preferred to go back to the definition of
Herpes given by the old Greek writers, or endeavoured to frame defi-
nitions of their own apphcable to its various forms. Thus, among
the Germans, Joseph Frank mentions this disease now by the name of
Hitzbläschen or "Fieberbläschen''''^ {Ilerpes labialis), now under
the head of " Flechten,^^~ now as a separate affection which he terms
Zoster,' and which he describes as entirely distinct from the other
kinds of Herpes.

Again, Fuchs makes an arbitrary division of the affections de-
scribed by Willan under the name of Herpes. Some of these he
includes in his family of " Eczematosen," belonging to the class of
" Dermatonosen;" and he terms these the II. miliaris s.pldyctcenoiäes,
and the II. figuratus. He also enumerates under the same head, as
varieties, the //. circinafus and the II. Iris. But he treats of Zos-
ter as a distinct disease, placing it among the " Dermexanthesen,^'
the 3rd order of his 23rd class, the " Erysipelatosen.^'

Y. Bärensprung considers that the term Herpes properly belongs
only to a parasitic skin affection, which makes good its claim to
that title by its annular form, and by its creeping (kriechend) charac-
ter, and which is further distinguished by being communicable from
one patient to another. Thus, he thinks that the use of this name
should be confined to the //. circinaius, the ring-worm of English
writers, the Torrigo scutulata of "VVillan, the Herpes tonsurans of
Cazenave. Zoster and the //. labialis and //. prajnitialis (which
are allied to it), are placed by him in a distinct species, to which
he gives the name of Gürtelkrankheit.

Besides tlie accounts of Zoster to be found in some of the older
medical works (such as that of Mehlis'^), this affection has, within
the last few years, been described by many writers of note, and
particularly by v. Bärensprung,^ Joswich,'' Gerhardt,''' Singer,^
Eomberg, and Heusinger. The Herpes tonsurans, as Cazenave
named it, was formerly treated of by Plumbe and Mahon ; and more

' Op. cit.j Band iii, p. 9.

' Ibid., p. 137.

3 Ibid., Baud ii, p. 618.

* ' Commentalio de Morbis Hominis dextri et sinistri,' Göttingen, 1818.

* 'Die Gürtelkrankheir,' Berlin, 1861.
^ 'De Zoostere,' Halite, 1852.

' 'Jen. Ztschr.,' ii, 3, 1865.

8 ' Allg. Wien. Med. Zeit.*,' 1858, p. 209.

DEFINITION. 365

recently full descriptions of it have been published by Malmsten^
Gruby^ Bazin^ Köbner/ and myself.^

If we look over the historical account of Herpes given above, we
find that this term has been employed in three distinct senses.
Firstj it has been used as a comprehensive name for chronic skin
affections in general, or, as they were called, Elechteniibel, Dartres,
Tetters, Erpeti, &c. Secondly, it has been applied to an acute dis-
ease of the skin, attended with the formation of vesicles, and occu-
pying particular regions of the body. In this case it is made a
generic term, including several species, among which is Zoster.
Thirdly, it has been employed to designate an affection caused by
the growth of a vegetable parasite, and taking the form of red scaly
patches, or of groups of vesicles and rings, or, again, leading to the
loss of the hair; this last variety being that which was formerly
known as " Tinea tondens,^'' and which has been termed by Willan
" Porrigo scutulata/' by other English writers " ringworm,''^ by
Gruby '' Rhizophito-alopecia,'' by Köbner " Mycosis tonsurans,'^
by Bazin " Teigne tonsurante,'"' and by Cazenave " Herpes tonsu-
rans.''^ Malmsten gave to the vegetable parasite found in this
disease the name of Tncliopliijton tonsurans.

This multiplication of terms is certainly of no advantage to der-
matology ; and one cannot but remark that Willan and Cazenave
might easily have chosen different names for the affections which
they described. But as they did not adopt this course, it seems to
me more advisable to adhere to the use of appellations which are
established, rather than to introduce still further confusion into
medical nomenclature by inventing new ones.

Por this reason, I adopt the definition of Herpes given by Willan.
I understand by this term a disease of the skin, having the following
characters : — It is benign, runs an acute course, and is attended with
the formation of miliary jpajpules, winch are arranged i?i groups, and
generally undergo development into vesicles and jmstules as large as
lentils, or even still higger. It is never distributed over large tracts
of the cutaneous surface, being ahvays confined to certain definite
regions. After remaining a few days, or as long as four iceehs, this

' Klinisclie MitUicilungen aus der Dermatologie und Syphilidologic,'
Eilaugeu, 1864 ; Mycosis tonsurans, p. 6.
* • Ztscluft. der k. k. Gesellschaft d. Aerzte,' 10 Jahrgang, 2 Baud, p. 473.

366 HERPES.

eruption dries up into flat crusts, tvhich often leave scars lohen ihei/
fall off.

This defiuitiou, however, requires to be modified to a certain ex-
tent, according to the seat of the affection. In different parts of the
body there are diflferences in the relative importance of its symptoms,
as well as in the way in which the vesicles are grouped, and in the
pattern of the disease.

It is therefore necessary to divide the genus Herpes into several
species, which require separate description. I accordingly distinguish
the following :

a. Herpes labialis, or, as I prefer to term it, H. facialis.

b. H. prceputialis, or rather H. progenitalis.

c. H. Zoster.

d. H. Iris et circinatus.

In the important work to which I have already referred, and
which has hardly received the attention which it deserves, v. Bären-
sprung suggests that the first three of these species of Herpes are in
reaHty but one aflfection, and should be included under the name of
Zoster. The reasons which he gives for this opinion are, that they
are all found in regions supplied by particular nerves, and that the
development of the vesicles is, in all of them, due to some morbid
condition of the nerve. When such vesicles occupy the whole ex-
tent of the part to which the affected nerve is distributed, a H.
Zoster is the result. He supposes that the //. labialis is an incom-
plete Z. facialis (answering to the infra-orbital and mental branches
of the second and third divisions of the fifth nerve), and that the
H. progenitalis is a rudimentary Z. sacro-ischiadicus et sacro-
geiiitalis, due to a morbid condition of the inferior pudendal nerves
and of branches of the pudic nerves, arising from the sacral plexus,
and supplied to the penis and scrotum, or to the labia.

But, plausible as this view is, and supported by anatomical con-
siderations, it nevertheless appears to me to be not altogether con-
sistent with clinical observations. To the practical physician, a
diagnosis resting upon an anatomical basis of ä conjectural kind
has no weight if it is in any way ojjposed by the symptoms of the
patient. In determining the essential nature of a disease, we should
certainly not attach more importance to its mere anatomical charac-
ters than to the results of observation at the bedside concerning its

SPECIES. 367

seat and distribution^ its course, and the complications by which
it is attended — particularly if these features are uniform at all
times and in every country in which the complaint is met with.
Indeed, in the case of Zoster, it was the clinical physician who drew
the attention of the anatomist to the fact that the disease is accom-
panied with a special nervous affection; and surely we ought to
listen to the opinion of the former with regard to the relation between
Zoster and the K. facialis and H. progenitalis, before doing away
with the separate existence of the last-mentioned species of Herpes.

Now, clinical observation furnishes us with many reasons for re-
taining the distinctions hitherto admitted between these forms of
Herpes. Among these reasons are the following : —

I . In the H. labialis and the H. praputialis there is generally
only one group, or but a very small number of groups, of vesicles ;
whereas in Zoster this is the case only in very exceptional instances,
several clusters being developed in succession.

3. Zoster seldom returns; it generally appears only once in the
life of an individual, whereas in H. labialis and H. progenitalis the
reappearance of the disease is the rule.

3. It is a well-known fact that Herpes labialis occurs in the train
of febrile complaints ; it has even received the name of Hydroa

febrilis. Hence this affection appears to be symptomatic, and due
to some past or actually existing disease attended or unattended
with fever; whereas Zoster is to be regarded as the result of a morbid
condition, more or less accurately confined to the tract supphed by
a particular cerebro-spinal nerve.

4. Neuralgic pains precede the eruption of Zoster, accompany it,
and often remain for a long time after its disappearance. This
symptom is never observed in the H. labialis or the H. prce-
putialis.

5. The H. labialis and progenitalis are not generally unilateral,
but more often affect both sides, or appear in the middle line of the
body. V. Barensprung,^ indeed, disputes the complete accuracy of
this ; but, as it appears to me, he is wrong in doing so.

Again, the H. Iris and the H. circinatus should, in my opinion^
be retained as distinct species; and I may here state my belief
that the second of these is not identical with the H. tonsurans of
Cazenave.

On the other hand, I do not admit the existence of a H. pldtjcim-
^ Op. cit., p. 18.

368 HERPES FACIALIS.

nodes (Willan), or of a H. squamusus (Cazenave). The first of these
is a partial Zoster, occurring chiefly on the limbs; the second is
probably a macular form of the H. tonsurans.

I now pass on to describe the different species of Herpes ; and
the first of these, in anatomical order, is the H. facialis.

I . llerj^es facialis, seu labialis. Hydroa fehrilis. (The Olophlyctis

of Alibert.)

Herpes may arise on any part of the face. It is certainly most
common on the lips, but it may occupy the nose (and even the nasal
mucous membrane), the cheeks, the forehead, the eyelids, the con-
junctiva ocuH, the external ear (//. auricular is), the red parts of the
lips, the inner surfaces of the lips and cheeks, the mucous membrane
of the oral cavity, and that of the hard and soft palate, of the
uvula, and even of the tongue (//. lingua). The a])pearance of this
affection when it attacks the skin is, however, different from that
which it assumes on the mucous membranes.

It is evident from what I have just stated that the name II.
facialis, being more comprehensive, is more applicable to this dis-
ease than that by which it is generally known. For it would cer-
tainly be strange to call an affection of the nose or forehead a
H. labialis.

On the cutaneous surface this eruption consists of vesicles dis-
tended with a clear watery fluid, and arranged in clusters. These
vesicles are rarely numerous, and there are generally only a few of
the clusters, all of which usually appear at the same time and pass
through their subsequent changes simultaneously. The outbreak
of a H. facialis is often preceded by a burning pain in the part,
but this finally disappears when the vesicles have become fully
developed. These are themselves of but short duration ; their con-
tents rarely become purulent, and soon dry up, with the epidermis
wliich formed the roof of the vesicles, into brown scabs ; and when
the scabs fall ofi", the skin beneath is found to have resumed its
normal appearance.

On the red parts of the lips the vesicles occupy a smaller area;
the fluid which they contain is not so clear and transparent ; they
generally coalesce, and quickly dry up into rather thick, brown
crusts.

"Within the oral cavity this afl'ection presents difitrent characters.

HERPES I'ACIALIS. 3G9

The formatiou of vesick's does not go beyond its earliest stage, for
the epithelium of the mucous membrane is too delicate to be able to
retain, for more tlian a very short time, the fluid which collects
beneath it. Hence, the vesicles soon burst, and we then perceive
a number of white spots, perhaps as large as lentils, due to the
macerated condition of the epithelium ; or, if this has become de-
tached, certain shallow excoriations mark the points previously
occu])ied by vesicles. The mucous membrane of the mouth being
continually washed with saliva and mucus, crusts cannot form upon
it in herpes, any more than in variola ; and when the white spots or
the shallow excoriations have remained for a short time, the part
returns to its normal condition.

The subjective symptoms to which herpetic affections of the
interior of the mouth give rise are merely such as would be produced
by excoriations, or by any changes which deprive the surface of its
natural covering. The patient complains of a burning sensation
when he speaks or chews any hard substance, or smokes tobacco, or
eats any hot, soui", very salt, or highly seasoned food.

When this disease affects the uvula, or other parts of the soft
palate, it is apt to be mistaken for an angina, in consequence of the
unpleasant sensations to which it gives rise. On the other hand,
herpes of the anterior part of the oral cavity, and especially of the
gums and tongue, may easily be confounded with aphthse.

An lierpetic affection of the skin of the face, the red parts of the
lips, and the mucous membrane of the mouth, sometimes occurs in
perfectly healthy subjects, being then the only morbid condition
which is to be detected ; but, in other instances, such an eruption
precedes or accompanies the outbreak of a febrile or non-febrile
complaint.

Now, it is true that the Herpes facialis appears more frequently
in intermittent fever, pleurisy, pneumonia, and certain catarrhal
maladies, than in other diseases. But it is no less certain that
this eruption may arise in the course of various complaints, and even
ill continued fever (Typhus) } It was long maintained that, even when
all the characteristic symptoms of this disease are f)resent, a case
must not be regarded as one of fever, if a H. labialis should deve-
lop itself; but further observation has shown that this is not
correct. I have myself seen, both during life and in the dead body,
the most marked herpetic eruptions in typical cases of fever. Yon

^ Viae note lo p. "oo.

370 HERPES PROGENITALIS.

Bärensprung,^ indeed^ clings to the older viewj having never himself
bserved herpes in a case of typhus ; but it can be regarded only as
an accident that such a combination has never presented itself to
nim, for all the physicians connected with the hospitals of this city
admit that it sometimes occurs^ and they are undoubtedly right.

Again, it was at one time fancied that the breaking out of a
Herpes labialis in the course of some other disease is a favorable
sign, indicating that a crisis has occurred, and that the progress of
the complaint is checked. But this notion also has been shown by
experience to be without foundation. Observation teaches that this
form of herpes is neither of good nor of bad augury, with reference
to the probable issue of the disease which it accompanies. We are
still altogether in the dark as to the relation between the H.
facialis and these complaints.

As to the liability to the recurrence of this affection, I may men-
tion that in some cases it returns at pretty regular intervals j as, for
instance, every month.

2. Kerjpes p'ogenitalis. H. praputialis (The H. psetidosypUlis

of Tuchs.)

This affection, although most commonly observed on the prepuce,
is not infrequent on the dorsum of the penis and on the glans.
Moreover, it may appear on the female genital organs, as, for
instance, on the labia or the mons veneris. It consists of vesicles,
generally few in number, containing a transparent fluid, arranged in
groups, and often forming one single group. The commencement
of this disease may or may not be preceded by sensations of burning
or pain ; in some cases it breaks out quite suddenly, accompanied
by these symptoms. Unless the vesicles are ruptured by scratching
or rubbing, this form of herj^es lasts only for a few days, for the
fluid soon dries up, and thin crusts are formed ; and Mdien these fall
off the surface is found to be healthy, or, perhaps, slightly red-
dened. But if the vesicles are injured by scratching, or are kept
constantly moist (as when they are seated on the inner lamina of
the prepuce), they often lose their epidermic covering, and pass into
excoriations; while, in other instances, they acquire a flat white
coating of uiaccratcd cuticle, and therefore look like small ulcers.

' Op. cit., p. 21.

HERPES PROGENITALIS. 371

Even when tliey present this appearance, however, they always
become covered with thin scabs, when the epidermis dries ; after-
wards, on the falhng off of these scabs, they heal, without leaving
any cicatrices.

But, although the description which I have just given of the
H. progeintalis is perfectly true to nature, yet I must not suppress
the fact that various impediments stand in the way of the recog-
nition of this affection in practice. Indeed, it is sometimes impos-
sible to determine whether we have to deal with a simple herpes or
with a syphilitic affection. It was this very difficulty whicli led the
syphilologists Hunter and Ricord to practise inoculation for dia-
gnostic purposes. For if it were, in every instance, so easy to dis-
tinguish a chancre or syphilitic ulcer from a herpes or sore which
is not syphilitic, these observers would have had no reason for
making it a conditio sine qiid non in the diagnosis of a chancre that
inoculation should be successful, and should produce a pustule.

I would insist particularly upon this point, because I have
repeatedly seen cases of this kind in which mistakes , have been
made even by professed syphilologists. The surest way to avoid
such errors is, no doubt, to perform inoculation ; but we may attain
the same end just as quickly without it, by simply making it a rule
to give no diagnosis until we have had an opportunity of watching
carefuUy the further course of the case. If the affection be a
herpes we shall find, within a few days, that all the morbid appear-
ances subside, leaving no induration nor any cicatrix; whereas in
syphilitic affections the surface of the excoriation or ulcer becomes
clean only after a longer period, the process of cicatrization takes
more time, and, after the sore has healed, its base still remains
indurated.

This form of herpes, like the H. facialis, is liable to recur.
Some persons, without any known cause, find herpetic eruptions on
their genital organs, perhaps five or six times a year \ and this may
go on for many years in succession, until, at last, the disease ceases
to make its appearance.

373 HERPES ZOSTER.

3. Berj)eH Zoster {Zona, Chujiduui, Shingles, Gürtelii echte,
Gürtelausschlag) .

This is the most important of the forms of herpes, and differs
in certain respects from all others. Thus, it is much more exten-
sive, the number of groups of vesicles being much larger. More-
over, the regions at which it is lialjle to occur are different; but
these are perfectly definite, and are well known.

The localisation of tliis disease was formerly much more strictly
limited, the only cases which received the name of //. Zoster being
those in which the eruption is seated on the trunk of the body (and
chiefly on the chest), and is confined to one half of it. farther
observation, however, has shown that, besides the chest, any part
of the trunk or limbs, and even the neck, face, or head, may
present a similar efflorescence, affecting one side only ; and that the
changes through which the vesicles pass, and the whole course of
the aflection, are in these cases exactly the same as in the disease
which occupies the trunk, and has always been regarded as the
typical form of Zoster.

My definition of this complaint is, then, much more comprehen-
sive than that which has hitherto been adopted. *' Medium hominem
amh\ens ignis sacer Zoster appeUatur!' (Plinius, 26, c. 11.) I
include under this name all those skin ati'ections which present the
characters of herpes, and in which the part of the surface occupied
by the groups of vesicles corresponds to the distribution of certain
cutaneous nerves, and which, lastly (whether occurring on the head,
trunk, or limbs), are confined to one half of the body. It is only
in rare and exceptional instances that Herpes Zoster attacks both
sides simultaneously.

I shall have, therefore, to describe certain varieties of this dis-
ease which occupy different regions of the body, and to which I
give the following names :

{ci) Zoster capillitii.

{tj) „ faciei.

{c) ,, nucha {s. IT. collaris.)

{(l) „ Irachialis.

(f) ,, pecloralis.

HERPES ZOSTER. 373

(/') Zosler ahdominalis.
(f/) }> feiiioralh}

^ V. Bdrenspmug lias giveii a somewliat different descriptiou of Herpes
Zoster, according to its place of origin and mode of distribution.

Now, althougli I tliink that the forms of zoster enumerated above by myself
arc quite sufficiently numerous, it nevertlieless appears to me to be desirable to
quote from the classical work of v. Bärensprung the names and general distri-
bution of the different varieties described by him. These are as follows : —

(«) The ^' Zoster facialis" always confined to one half of the face, occupies
the surfaces of the skin and mucous membranes supplied by the fifth nerve. A
form of it is the " Z. labialis"

{h) The " Zoster occipito-collaris" ioWovfs the distribution of the occipitalis
minor, auricularis maguus, and superficialis colli nerves, derived from the cervical
plexus.

(c) The " Zoster cervico-subclavicularis" corresponds to the descending (supra-
sternal, supra-clavicular, supra-acromial) superficial branches of the cervical
plexus.

{d) The " Zoster cervico-ljracJnalis" is due to a morbid condition of nerves
belonging to the brachial plexus. It may be confined to the upper arm
{Z. brachialis), or the forearm, or even the hand.

{e) The " Zoster dor so -pec lor alls ^ — la this form the affection begins over the
spinal column, generally occupying a surface corresponding to three vertebra2 ;
it spreads obliquely downwards to the side of the chest, and thence passes,
ascending slightly, to the sternum. The nerves concerned in this variety of
zoster are the third to the seventh dorsal.

(/) The " Zoster dorso-uhdominalis" affects the lower part of the back, its
upper limit being the eighth dorsal, its lower the first lumbar, vertebra. It
extends over the surface of the abdomen as far as the linea alba.

{ff) The " Zoster lumbo-inguinalis" begins in the lumbar region, and spreads
horizontally forwards to the linea alba, obliquely downwards and forwards to
the mons veneris and genital organs, and also downwards to the skin of the
gluteal region and the outer surface of the thigh. It corresponds to branches
of the upper lumbar nerves.

(//) The " Zoster lumbo-femoralis" occupies the distribution of the external
cutaneous, genito-crural, anterior crural, and obturator branches of the lumbar
plexus. The wide cutaneous distribution of these nerves enables us to under-
stand how extensive and severe this variety of herpes may sometimes be. la
other cases it is confined to the surface of the thigh, only certain branches of
these nerves being then affected {Z.femoralis).

(J,) The " Zoster sacro-ischiadiciii'' answers to the cutaneous supply of the
branches of the sacral plexus.

V. Bärensprung regards the " Zoster genitalis" (Herpes prreputii et vulvte)
as due to a partial affection of these nerves.

[An abstract of Prof. v. Bärensprung's paper on " Herpes " will be found
iu the ' British and Toreign Medico-Chirurgical Review ' for January, 1862,
p. 243.— Ed.]

I must in this place refer also to the elaborate investigations of Prof. Voigt

374 HERPES ZOSTER.

But, before passing on to give a detailed account of each of these
local varieties, I must remark that, in every one of them, a regular
form may be distinguished from certain modifications of it which
are abnormal. The following are the characters which I consider
to belong to this disease in its normal form.

1. The vesicular eruption presents the appearance which I have
described as belonging to herpes in general. It passes through
certain changes and subsides, leaving no cicatrices. I may also
remark in this place that the first-formed clusters of vesicles are
always nearest the nervous centres, and that those which subsequently
develop themselves lie more towards the remote peripheral distri-
bution of the corresponding nerves.

2. The rash is confined to one half of the body; but clusters of
the vesicles exist over the whole of the region which should present
them, according to the definition of the local variety of Herpes
Zoster to which the case belongs.

3. No extraordinarily severe pain precedes the appearance of the
rash, nor is its subsidence followed by any intense or long con-
tinued suffering.

4. The vesicles contain merely transparent scrum, or, in some
cases, a puriform fluid.

On the other hand, I regard as anomalous —

1. Those cases in which some part of the eruption (or the whole
of it) presents characters diS'ering from the normal type which I
have described. Thus, the rash sometimes remains in the papular
stage; while, in other instances, bullrr, arise, or pustules, which
attack the deeper structures of the skin, and are followed by cica-
trices.

2. Those exceptional instances, in which Herpes Zoster arises

with respect to the cutaneous distribution of the cerebro-spinal nerves, the
results of which investigations are given in liis work, ah"eady mentioned (see
page 249), published by the Imperial Academy of Sciences. Ou the head,
neck, and limbs, the tracts of nervous supply (Verästelungsgebiete) pointed out
by Voigt agree perfectly with the results of observation in cases of zoster. On
the trunk, however, the correspondence seems, at first sight, to fail. For the
dorsal and lumbar nerves are distributed to the skin by three separate sets of
branches (posterior, lateral, and anterior), which form as many "tracts of
nervous supply" iMinning vertically on either side of the body. In reality, how-
ever, each of tiie dorsal and lumbar nerves takes a separate course forwards from
the spine to the front of the trunk, and the position of the vesicles of zoster
accords perfectly with the distribution of these nerves.

HERPES ZOSTER. 375

symmetrically on both sides of the body ; and likewise those in which
only a few clusters of vesicles attain their full development, the
others being altogether absent, or appearing merely as minute points
(Pünktchen), which soon abort and die away.

3. Those in which severe neuralgia accompanies the attack of
shingles, preceding the eruption, or continuing even after the
vesicles have dried up into crusts. It often happens that the per-
sistence and the intensity of this symptom render the disease a very
painful one; and, in some cases, the functions of the motor nerves
also are interfered with.

4. Those, lastly, in which blood is mixed with the fluid contained
in the vesicles, or in which haemorrhage even occurs into their floors.
The eruption then has an appearance very different from that
which it usually presents ; it is the seat of most severe pain, and is
always followed by the formation of cicatrices.

I may now describe in order the local varieties of Herpes Zoster
which I have already mentioned.

{a) II. Zoster capillitii. — This often appears on the forehead and
scalp, in the course of the supra-orhital, a branch of the first divi-
sion of the fifth nerve, passing from the supra- orbital notch upwards
to the top of the head. In some of these cases the eye also is
affected ; the vessels of the conjunctiva and those which supply the
cornea being injected, and severe pain being complained of by the
patient. Under these circumstances, indeed, the mobility of the
iris may be so much impaired that the disease may simulate an
Iritis.

In other instances the eruption begins at the back of the head,
spreads in the form of an arch over one parietal bone, and termi-
nates in the neighbourhood of the coronal suture. This variety of
Herpes Zoster is well seen only in persons who are bald ; and such a
case may be found in the first number of Boeck''s 'Atlas der Haut-
JcranJcJieiteii' In a patient whose head is thickly covered with
hair, it is difficult to detect this form of shingles.

[b) H. Zoster faciei. — In this variety numerous clusters of
vesicles develop themselves on the cheek, whence they pass over
the side of the nose towards its bridge, gradually becoming smaller
as they approach this point. I have twice seen this affection bila-
teral. It then appeared quite symmetrically on the two sides of
the face, and gave the patient scarcely any pain.

370 HERPES ZOSTKiL

(<?) //. Zoster nucha (the K. collar is of Plenck, the Z. occijjiio-
collaris of v. Bärenspruug) . lu this form of shingles the eruption
first makes its appearance on the side of the neck over the second
and third cervical vertebrEE^ and extends thence upwards towards
the lower jaw and face, forwards over the larynx, and, lastly, down-
wards, a few clusters reaching even as far as the second rib.^

{(J) H. Zoster hrachialis. — In this variety the first vesicles appear
opposite the fifth, sixth, and seventh cervical, and the first dorsal
vertebra ; and the affection then passes down the arro, occupying
both the extensor and the flexor surface (but especially the latter),
and extending down to the elbow, or even along the forearm, as far
as the little finger. The whole of the skin supphed by the brachial
plexus, down to the peripheral distiibution of the radial and ulnar
nerves, may thus be the seat of shhigles,

(e) //. Zoster ])edor alls. — "When Herpes Zoster breaks out on the
surface of the chest its distribution in general corresponds with the
inclination of the ribs ; for the groups of vesicles run parallel with
them, or rather with the intercostal nerves, the direction of which
is the same as that of the ribs. Near the s])inous processes, where
the earliest clusters make their appearance, the vesicles cover an
area answering to two or three vertebrae. From this point the
eruption at first passes downwards over the side of the thorax, but
afterwards ascends on approaching the anterior wall of that region,
and terminates over the sternum in the median line of the body.

In its progress round the chest the Herj^es Zoster does not spare
the skin over the breast, as has been erroneously asserted by some
writers. Another point which may be mentioned is that in this
form of shingles the ]:)ain is frequently so severe and so intensified
by the movements of respiration that it gives rise to dyspnoea.
Indeed, the affection may in this case be easily mistaken for a
pleurisy in its early stage.

[f] H. Zoster ahdorainalis. — This variety corresponds to the
distribution of the lower dorsal and lumbar nerves, which supply
the muscles and skin of the abdomhial wall. The eruption passes
forwards round the abdomen, and terminates in the median line, a

1 Vide Cazenave, ' Lecons sur les Maladies de la Peau,' JParis, 1856, p. 41,
Planche 8. '

HERPES ZÜSiER. 377

few clusters of vesicles often appearing on tlie mons veneris. In
]nany cases of this affection the movements of inspiration and expi-
ration, and all straining efforts of the abdominal muscles, give rise
to pain, as in the //. Zoster j^edoralls, though not to the same degree
as in that form of the disease.

{(j) H. Zoster ferao rail 8. — This appears sometimes on the anterior,
sometimes on the posterior, surface of the thigh ; and, in the latter
case, may extend down as far as the ham or even to the calf of the
leg. The first cluster of vesicles is generally observed on the but-
tock ; indeed, the affection often remains limited to this part, in-
stead of spreading downwards.

Whether attended or not with febrile symptoms, Herpes Zoster
is always preceded by pain of more or less intensity. But this
symptom is by no means sufficiently characteristic to enable us,
when it alone is present, to infer with any degree of certainty
that an attack of shingles is impending. In fact, a positive
diagnosis cannot be made until the eruption appears in the form
of points (Stippcheu), papules, or vesicles, arranged in groups, and
occupying the parts of the surface above mentioned, and until the
affection begins to sj^read in the manner I have already described.

All the vesicles in any one cluster always appear simultaneously,
and are therefore coeval. Hence they invariably all present the same
characters. In some instances they assume the vesicular form so
quickly, that the earlier stages of their development altogether escape
notice. In other cases they pass gradually from papules into
vesicles having an umbilicus ; the changes which they then undergo
being just the same as those through which the smallpox eruption
passes. Indeed, the fluid contained in these herpetic vesicles after-
wards becomes opaque and puriform ; and thus they also are con-
verted into pustules. A little later still a red border forms round
each of these pustules, so that, if they are closely packed together,
they appear to be seated on a common red base. At the end of some
days their contents dry up, forming firmly adherent crusts of a
yellow or brown colour. When these crusts fall oft', the skin is
found to be marked by shallow depressions, and it may even present
permanent cicatrices.

The number of distinct clusters of vesicles is not the same in all
the forms of shingles. They are fewest in a //. Zoster facialis,

378 HERPES IRIS ET CIRCINATUS.

and most numerous in a fully developed //. Zoster femoralis ; the
difference being, of course, fully explained by the fact that the
surface affected is in the one case very much smaller than in the
other.

Herpes Zoster lasts from two to four weeks, according to the extent
of surface affected by it, or (what is much the same thing) the
quantity of the eruption.

The changes through which the vesicles pass are invariably such
as I have described above. Except the pain, which precedes the
eruption, and is often particularly severe after decrustation has
taken place, the only impleasant s}Tnptom ever observed in cases of
shingles is the continuance of suppuration (and even, in some in-
stances, the occurrence of ulceration), beneath one or two of the
crusts, when the deeper structures of the skin happen to be
affected.

Herpes Zoster invariably terminates in recovery. The only con-
dition under which we are hkcly to see a case of shingles on the
deadhouse table is that of the patient having succiunbed to some
other disease.

4. Herpes Iris et circinatiis.

These species of herpes were first observed and described under
these names by ^Yillan. They ])rcseut the follomng characters :

The Herpes Iris consists of groups of vesicles, arranged in a pecu-
liar manner. A vesicular ring (Bläschenkranz oder Bläschenwall)
surrounds a central vesicle ; outside this ring, at a little distance, a
second one sometimes exists ; and even a third is sometimes observed,
all of them being concentric. It seldom happens that all the groups
of vesicles exhibit these characters, which are generally confined to
a few of the clusters, or may even belong to one of them only ; the
vesicles in the other groups having coalesced so as to form bullse, or
being very few in number, and merely placed side by side.

This remarkable disease owes its peculiar form to the fact, that
the vesicles subsequently developed arrange themselves round the
one which first made its appearance, and thus comes to occu23y their
centre. In other words, successive outbreaks (Nachschübe) occur,
the new vesicles being placed as close as possible to, and therefore
round the circumference of, those which preceded them. There are, in-
deed, other diseases of the skin, in which the efflorescence, in any sub-

HERPES IRIS ET CIRCINATUS. 379

sequent outbreaks^ occupies the immediate neiglibourliood of that
which first appeared ; and thus Herpes Iris bears a resemblance to
these affections, among which are certain forms of variola, during
the stadium decrustationis, or (in the case of varicella of the trunk
of the body) even during the stadium eruptionis. For we frequently
find, round the crusts formed by the desiccation of the earliest small-
pox pustules, vesicular rings, produced by a subsequent exudative
process. This often gives to the affection the appearance of a Herpes
Iris, or, in some instances, rather of a rupia; the latter being the case
particularly when the further changes arise at a time when the first-
formed pustules have already dried up, and formed crusts.

The course of this form of herpes differs in some cases from that
of the previously described species, in the fact that the peripheral
development of vesicles continues for some time, while the central
one is already undergoing involution, so that at last nothing is to be
seen but vesicular rings, surromidiug a central space which may be
the seat of pigment, or covered with scales, or even abeady re-
stored to a normal condition.

These were probably the cases which caused Willan to form the
species known as the Herpes circinafus. I am, however, unable
to admit the existence of this affection as a special form of the
disease. I have never seen such vesicular rings apart from the
mode of development which I have just described, and I must
therefore regard them merely as instances of a Herpes Iris, spread-
ing at the periphery.

The H. Iris, then, bears the same relation to the so-called
H. circinatus that the Erythema Iris bears to the II. annulare : just
as this last always develops itself from an U. papulatum or an
U. Iris, so does a H. circinatus always arise from a H. Iris. More-
over, all these affections correspond so markedly in theii' com'se and
form, as well as in their mode of development and in their seat,
that I am greatly tempted to regard them all as modifications
of the same disease. Indeed, the truth of this vicAV is rendered
certain by cases which I have had occasion to observe, in which
there have been present at one and the same time appearances which
were, at some points, those of the Herpes Iris and circinatus ; at
others, those of the Erythema papulatum. Iris, and annulare.

Like the corresponding forms of erythema, the Herpes Iris and cir-
cinatus appear most frequently en the backs of the hands and feet
and on the fins:ers and toes, and next on the forearms and legs. They

380 HERPES IRIS ET ClRCIxXATUS.

are less commoul}' observed on the upper arms or the thighs^ and
only in exceptional cases on the trunk or the face. But although a
universal H. Iris is thus a very rare affection^ it yet does sometimes
occur, and I have had occasion to see it.

We may find a further analogy between the affections of which I
am speaking, in the circumstance that all these forms, both of
erythema and of herpes, have a tendency to recur for several years in
succession in the same month, this l)eing generally either April,
May, October, or November.

The duration of a //. Iris depends on the number of rings which
are successively foruied. If the affection terminates Avith the forma-
tion of the first vesicle, or after a few succeeding ones, it runs
through its course in a fortnight, without any further consequences
than sliglit desquamation and pigment deposit. If, however, a
II. circinatus develops itself, that is, if rings are repeatedly formed
round the orighial vesicle, the duration of the disease may easily
extend to a month.

The sympathy of the organism generally is for the most part very
slight, so that the patient often has his attention directed to the
presence of the eruption merely by unpleasant sensations of burning,
or perhaps itching, at the spots which are occupied by it. Neither
fever nor any gastric nor cerebral symptoms — neither affections of
the mucous surfaces, nor of the serous or fibrous structures — are
present in these forms of herpes. I do not, however, mean to
assert that the //. Iris is a merely local complaint ; it may, perhaps,
rather be that tlie general disturbance, which was the cause of the
eruption, has vanished before the first herpetic vesicles make their
appearance.

Herpes Iris sometimes deviates from its regular course, present-
ing bullse instead of vesicles arranged in the peculiar manner above
described. These bullae are to be attributed to the rapid nmning
together of the indi\idual vesicles. They are, however, like those
of Femphigus in that they remain throughout the whole time
of their existence without any further circumvallation. Ultimately
their contents dry up or evaporate, or their roof gives way, breakmg
up iuto loose fragments of epidermis of greater or less size. The
bullae then undergo involution ; and their course is, in fact, no less
acute than in the ordinary forms of herpes. It is probable that it
has been this variety of li. Iris which has led some observers, im-
perfectly acquainted with cutaneous diseases, to admit a Pemphigus

ETIOLOGY OF HEllPKS. 381

acutus, as to the existence of -which I have great doubts. For
those who may be inchued to regard as instances of pemphigus these
cases of H. Iris, I may here mention that even in this unusual
form the affection always presents characters sufficient to enable a
diagnosis to be made. This may, in fact, be arrived at, either by
observing the seat of the disease, or by noticing that some one or
other of the groups of vesicles has not become so perfectly confluent
that the peculiar concentric arrangement can no longer be detected.
I have had occasion to observe the H. Iris, in both its regular
and irregular forms, most frequently in young subjects, and in the
female more often than in the male sex. I do not, however, mean
to assert that this complaint is, in reality, more common in Avomen.
The fact may, perhaps, be due to the circumstance that men are less
likely to apply for medical treatment on account of a disease which
is trifling and painless^ and undergoes spontaneous involution, than
women, yx\\o always pay more attention to their outward appearance,
and who are never indifi'erent to the presence of a cutaneous
affection, occmTing on a part of the surface which is usually mico-
vered. I therefore merely record it, without drawing from it any
further inferences. It is at least certain that the H. Iris bears no
relation to the genital functions in either sex, and that it is never
caused by syphihs.

Etiology of Herpes. — It would be very difficult to find any
grounds for asserting that all the forms of herpes owe their origin to
one and the same remote cause. Indeed, it is more probable that all
these species, or, at any rate, several of them, may be in relation in-
dii-ectly, if not immediately, with various conditions. Thus, it would
be difficult to believe that the H. procjenitaUs and the H. Iris derive
their origin from the same source. And, on the other hand, it would
also be no easy task to show^ clearly that different morbid states give
rise tO' them, and what these diflerent states are.

I may take as an example the IL facialis. This affection, as is
well known, may accompany maladies, such as intermittent fever or
pneumonia, which apparently differ widely from each other. Now
this surely is a powerful argument in favour of the opinion ex-
pressed above, that the cause of herpes is not always the same. On
the other hand, observations as to the scat and mode of distri-
bution of Herpes Zoster lead us to ascribe its origin to perverted
innervation. Hence, if we choose to np])ly what is irne of H.

3S2 TREATMENT OF HERPES.

Zoster to the other forms of herpes also, it appears probable
that the varied diseases above referred to (some of which are
inflammatory, ■while others are among the so-called nervous dis-
orders) all generate this peculiar skin affection by acting upon the
peripheral nervous system.

Treatment of Herpes. — The fact already mentioned, that each of
the forms of herpes terminates within a tolerably short time, is
sufficient to show that any special treatment of this disease is un-
necessary.

Moreover, experience teaches that it is not a matter of indifference
whether we do or do not apply local remedies directly to an herpetic
eruption, for their effect is always to retard the progress of the affection
and to increase the disagreeable sensations which the disease itself is
apt to cause. I refer particularly to the cctrotic mode of treat-
ment, that is to say, to the destruction of the individual vesicles by
means of nitrate of silver, which has been recommended in herpes
as well as in other vesicular forms of cutaneous disease. By this
procedure we neither hasten the termination of the complaint, nor
diminish the chances of the formation of cicatrices, nor the proba-
bility that relapses may occur. We merely add to the pain caused
by the disease that which results from the application of the
caustic.

The same may be said also of the irritants which have sometimes
been made use of, such as vesicants and sinapisms. These have
been employed by some at the first onset of herpes, with the object
of bringing out the eruption. At the time when the vesicles
of herpes were generally supposed to contain a materia peccans
which the organism was stri^^ng to throw out upon the cutaneous
surface, the application of these ii-ritants to the skin w^as certainly
excusable. But now that this idea has fallen to the ground there
is no justification for such' a jn-oceedui*e, which, in fact^ merely
increases the pain.

Experience, then, teaches that an expectant treatment is the best,
so long as an herpetic eruption is present. It is much to be
wished that the same could be said with regard to the neuralgic
pains caused by these affections, which sometimes give the patient
great distress, and are particularly severe in cases of Herpes Zoster.
The expectant method is, indeed, the only one which can be
employed, for, at any rate, most of the remedies which have

MILIARIA. 383

been tried iu the hope of relieving these paius have proved unsuc-
cessful. It has, however, sometimes hapj)ened that advantage has
been derived from the use of local or even internal remedies m
these cases. Thus, narcotics applied in the form of plasters or
ointments to the spots covered with herpetic vesicles do, in some
cases, relieve the severe pains, particularly if pressure is at the
same time applied by means of a bandage. For this purpose any
plaster may be employed which contains but little turpentine (such
as either the Ernpl. diabotanum, the TLmpl. lithargyn fuscum, or the
Empl. de meliloto) , spread upon long strips of linen or leather, and
dusted over with powdered opium. The plaster may be kept in its
place either by an ordinary bandage or by means of a towel folded
several times and fastened tightly round the body. The dressing must
be changed at least once a week. I have frequently seen the pain
relieved by these appHcations. Again, the pain may often be ob-
served to disappear under the internal use of narcotic remedies,
Avith or without quinine. But, unfortunately, this is not always
the case, and I do not think that the administration of internal
medicines is really preferable to local treatment. In my experience
I have never seen any good results either from cold lotions, from
hot fomentations, or from the use of collodion, tincture of iodine,
narcotics, or epispasticsj or, lastly, from anaesthetics, such as
chloroform, ether, or the Liquor Hollandicus.

II. Miliaria. (Friesel.)

Before giving a definition of the word Miliaria, as I understand
it, I must, in a short historical retrospect, give an account of the
meanings which various writers in different countries attach to this
term, and also of the ways in which it has in past ages been
employed.

Mention is made in medical works of a Miliaria rubra, a M. alba,
and a M. crystallina. The first of these is described as consisting
in an eruption of distinct, red, pointed papules or vesicles, of the
size of millet-seeds (whence the name Miliaria) . Whether they are
papules or vesicles depends on the amount of fluid present. They
are generally developed rather rapidly, but are invariably preceded
l)y move or less profuse sweating ; they are not of very long dura-

384 MILIARIA.

tiou. When the summits of tlie papules or vesicles have a white,
milky, or opalesceut appearance, caused by the action of the fluid
on the epidermic layers which form theii* roof, filename Ililiaria alba
is applied to them ; but this affection is in all other respects iden-
tical with the 31. rubra. Both these forms of efflorescence are met
AAdtli in healthy persons as well as in those who are the subjects of
disease.

On the other hand, the M. crystallina is described as an eruption
of vesicles containing a watery transparent fluid, and resembling
dew-drops in appearance. They occur prmcipally on the front and
sides of the chest, on the skin of the axillpe, and on the abdomeu,
but they may, in exceptional cases, be fonud on the limbs. They
are met with even in cases in which there has been no sweating
(ohne Proruption von Scliweiss), but only in patients suffering froui
fever (bei Eieb erkranken) .

Now, the last of these forms of miliaria spoken of by medical
writers is the only one to which, in my opinion, the name is cor-
rectly applied. For I have been unable to distinguish by any cha-
racters (whether subjective or objective) the M. rubra and the
M. alba from the affection known under the name of sudamiua
(Schweissbläschen, Eczema sndamen), which may arise whenever
there is profuse sweating, and Avhich consists in a swelling of the
canals of the hair-sacs and sebaceous glands, due to the irritation of
the skin. Hence, I venture positively to assert that both these
varieties are to be classed under the sudamina, and have no clami
whatever to the name of rniliaria. I shall therefore reserve the
description of them for the chapter on Eczema, to which they natu-
rally and properly belong.

I am convinced, then, — and this opinion is shared by all the
clinical teachers and physicians of Yienna, — that the only form of
miliaria is the M. crystallina, and that this is quite distinct from
the two others of which I have been speaking. It is, in fact,
a special eruption, which accompanies general disorders of a febrile
kind.

Thus, I have no acquaintance with the form of miliaria which is m
some works described as M. suhstantiva, exanthematica (Friesel-
ausschlag), and Avhich is said by so many authors to occur both
epidemically and endemicall3^ With regard to the M. crystallina,
the opinions Avhich I have been led to form by clinical observation
will be stated further on. In this place I will nieif'ly say that tliere

MILIARIA. 385

is no febrile disease in the com-se of wliicli the il/. crijdallina (Eriesel-
bläschen) may not appear.

Again, we find that authors, in describing miKaria; divide its
course into several stages, ascribing special characters to each.
Now I must confess that what is said of these divisions and their
characteristic symptoms is entirely irreconcilable \nth my view of
this affection ; for experience has taught me that miliaria diflTers al-
together, both in its commencement and in its course, from the
description of it given by these writers.

In my patients I have never observed the occurrence of the
so-called stad'mm ^^rodomorum, which is said to be characterised
especially by unpleasant sensations in the skin, and particularly in the
fingers and toes ; which sensations have received the name of süipor
2mngitivus. Nor have I been able to recognise the special form
of angina pectoris, the oppression at the chest, and the difficulty of
breathing, to which the writers in question have chosen to give the
title of anxietas prcecordialis ; nor to detect, by my organ of smell,
the peculiar odour, said to resemble that of decomposing straw. I
have, in fact, observed no single subjective or objective symptom
which has preceded the eruption in every instance of miliaria. On the
contrary, this affection has always made its appearance unexpectedly,
and without any symptoms to draw my attention to its approach. I
am therefore of opinion that it presents no objective or subjective
phenomena which justify the creation of a sladium prodromomiu.

In the Stadium erupt'wnis the vesicles are said to be found prhi-
cipally on parts protected by the dress or the bed-clothes, and con-
sequently not exposed to the access of air. But this is quite
imaginary ; for the eruption of miliaria may be observed over the
sternal and clavicular regions — which are scarcely or not at all
covered — and on the neck and throat, as well as on the sides of the
chest, the axillae, and the abdomen, — which parts, being protected
by the clothes, are of course often of a higher temperature.

In reference to the mode of development of the vesicles, and
their form during this stage, I have only to say that they always
remain of the same size as when they first make their appearance.
A quantity of fluid seems suddenly to coUect beneath the epidermis,
raising the cuticle so as to form vesicles of greater or less size.
These vesicles, being of the same colour as the rest of the skin, are
often detected more easily by the touch than by the sight ; and thus
our attention may be drawn to their presence by the rough, uneven

386 MILIARIA.

feel of the siu'face, Avhicli before was smootli. They always retain
the same form and the same size; and they never coalesce.

In regard to their size, the smallest of these vesicles are cer-
tainly no bigger than millet-seeds ; bnt the majority of them attain
the size of lentils, and some even present the characters of bullse,
being as large as beans or hazel-nuts.

Generally speaking, large numbers of them appear at once, and fresh
ones are developed in the course of the next few days. Their
duration varies in different cases ; it is not possible, as in the
exanthemata, to state precisely how many days they remain visible.
They sometimes last only forty-eight hours, and in other instances
they continue unchanged for weeks. In the cases which have come
before me, I have never been able to confirm the statements of some
writers, and particularly Fuchs, that there is a fresh eruption of vesi-
cles every day for seven days, and that each of these eruptions has a
duration of seven days, so that the whole complaint lasts a fortnight.
The fluid contained in the vesicles of miliaria has a neutral or
feebly alkaline reaction, and is not ever acid, as has been stated. It
never becomes pui'iform.

A special stadium desquamation is, again, is Avanting in this exan-
them. The epidermic roofs of the vesicles are, in fact, so thin and
delicate, that when the vesicles bui-st they are torn away, and nothing-
remains but a fine cii'cular edge of epidermis. Hence no shedding
of the epidermis (Defurfuratio), such as occurs in morbilli and
scarlatina, is observed in miliaria, particularly as the sweating con-
tinues, which is generally profuse in this disease.

From the description above given, it appears that miharia docs not
})üssess the same characters as the exanthemata proper, and, there-
fore, that it is not well to classify it with these diseases. We cannot
recognise in this affection any definite stages, distinguished by special
signs or by a definite duration ; and it is not constantly attended by
any morbid changes in other parts of the organism, such as in all
the true exanthemata are required to complete the perfect type of
the disease. I refer, for example, to the catarrhal symptoms of
measles and the sore throat of scarlet fever.

However, in works written before the present century, as well as in
those which have recently appeared, and even in special treatises upon
this affection,^ we not only find the characters of a sporadic exan-

' Vide ' Der Friesel, eine bistoriscli-patholog. UntersucLuug von Prof. Dr.
l^-auz Seitz.' Erlangen, 1852. Verlag von F. Enke.

MILIARIA. 387

tliein (such as purpura) attributed to the '^Friesel,'' but it is actually
described as a contagious disease^ and even as occurring in an endemic,
and in an epidemic form. To explain these statements, we must either
assume the course of the affection to have been in former times
and in other countries altogether different from what it is with
us, or we must suppose, which appears more probable, that other
exanthematic disorders have been and still are frequently confounded
with it. To this last opinion I have been led, not only by repeated
conversations with physicians, such as Helm and Cipriani, who
liave long been clinical teachers in those countries in which the
Miliaria endemica is said to occur, but also by the observations
which I have myself had an opportunity of making in the Italian
hospitals. I there frequently saw the word " Miliaria^' placed on the
card at the head of the patient's bed ; but the patient who lay in
the bed invariably presented simple sudamina or some other cutaneous
affection, or was suffering from typhus, heart disease or rheumatism,
or had been recently confined. Now these are the very conditions
under which miliaria is apt to occur even in our own country, as an
accidental and quite unimportant complication.-^

^ To meet tlie reproaches which may, perhaps, from some quarters be cast
upon me, that I am deaf to the teachings of the history of medicine, or igno-
rant of the literature of this subject, I will avow my belief that it is our
main task to study the origin, course, and distribution of diseases as they
exist now, and not to inquire what they were formerly. He only who is ac-
quainted with the present, can derive benefit from a study of the past. He
wlio will learn medicine must betake himself first to the bedside and the
post-mortem table, and not to the library. The study of the history of our
art should form, not the foundation, but the completion of our labours.
. If, in reference to miliaria, writers on medicine had adopted this plan, they
would, indeed, have been able to fill no large volumes ; but they might have
covered a few pages with descriptions true to nature, which would have been
of more service to science than all the folios they have published.

But during the last twenty years, in the course of which time I have had
under my care, in hospital practice alone, more than 80,000 cases of cutaneous
disease, I have constantly found that, with regard to the most common skin
afi'ections (such, for example, as scabies), opinions prevail which are quite incor-
rect, and are certainly not creditable either to medicine as a science, or to medical
men as its representatives. Indeed, it commonly happens that men well
skilled in surgery and in internal medicine display but slight interest in anything
that concerns cutaneous disease. Those who, like myself, have daily occasion
to notice these facts will not be surprised that in works which appeared
before the present century the distinctions between different diseases are often
obscure and uncertain. Indeed, this may be in part attributed to the medical

388 MILIARIA.

But although I deny the existence of miliaria as a special con-
tagious exauthem^ liable to occur endemically or epidemically, I am
nevertheless well aware that there is a vesicular affection which is
observed with especial frequency in certain diseases ; namely —

1. In Tijphus [Miliaria it/pJwsa). — In this disease the vesicles
generally arise during the second part of its course, being seen on
the surface of the trunk and limbs. An eruption of this kind is
very common in certain epidemics, while in others it is rare. It
does not in any way affect the ]n'ogress of the com])laint, appearing
equally often in cases which terminate favorably and in those
Avliich prove fatal and give us an opportunity of demonstrating the
presence of vesicles after death.

2. In Puerj^eral fever [Miliaria puerperalis) . — It being well
known that puerperal fever is often epidemic, and that in lying-in
hospitals it is sometimes endemic, we can easily understand that,
when the vesicles of miliaria devclope themselves in such cases, they
may be regarded as belonging to an epidemic miliaria ; a disease
which, indeed, according to Seitz, appeared for the first time during
an epidemic of puerperal fever at Leipzig, in the year 1650. It is
asserted that the Miliaria nferina (for this is the name given to the
miliaria which accompanies puerperal fever) presents itself on the
abdomen and thighs of lying-in women, ])articularly when these
parts, for fear of the patient catching cold, have been kept too warm,
or covered with poultices. But I have seen eruptions of Miliaria
crj/slallina in women recently confined, in cases in which no sudorific
medicine had been given, and no poultices had been used. The
vesicles have then been present on the chest and neck, as well as on
the abdomen.

3. In the so-called Acute articular rheumatism. — This morbid
process (which is certainly worthy of another name and of more
accurate investigation) is frequently attended with an eruption of
transparent miliary vesicles. These are observed not only when the
joints are covered with cotton-Avool or tow, and when hot fomen-
tations are applied to them, but also in cases treated upon an expec-
tant plan, or by ice-cold applications (Eisumschläge).

Asis well known, this disease is often accompanied by inflammation
of the pericardium, heart, lungs, or pleura — or, in other words, by

opinions of those days, when less attention was paid to tlie form of a cuta-
neous affection, than to its imaginary source in a swect-or sour, thin or tliick,
state of the blood.

MILIARIA. 389

aiFections of the organs which he in the thoracic cavity ; and in this
sense there is a warrant for the expression " Miliaria pectoralis sen
cardiaca." But it must not be supposed that the miHaria occurs
only as a result of disease of the heart, for this is not the case.

4. In the different exanthemata {Miliaria exantliematica), and
particularly in Scarlatina, constituting the " Scarlatina miliaris." —
This affection modifies to a certain extent the appearance of the
disease, inasmuch as a number of small, whitish vesicles are seen
scattered over the parts of the skin covered by the ordinary scarlet
rash. These vesicles are frequently of a müky-white colour, and,
therefore, might seem to be instances of the so-called "JtfzY/an«
alba'' of authors, rather than of the Miliaria crystallina. However,
they incontestably belong to the latter affection, as is very evident in
certain cases in which both transparent and "milky vesicles are present,
the latter being developed from the former. In variola, again, an
eruption of well-marked mihary vesicles frequently appears after the
tenth day of the disease, occupying the intervals between the different
pustules. In this instance, however, there are so many other morbid
appearances on the skin (such as pustules, crusts, and purpuric
spots), that the vesicles are not generally recognised as belonging to
miliaria. Indeed, they always make a great alteration in the appear-
ance of the case ; but they are nevertheless ordinary mihary vesicles.
This is proved by the further course which they take ; for, instead of
their contents becoming puriform, the lamellee of epidermis which
form their roofs burst or fall in, and finally become detached, as
is the case in the ordinary forms of miliaria.

5. The diseases above named are not, however, the only ones in
which eruptions of miliaria occur. It is, in fact, impossible to
enumerate all the complaints which may be accompanied by this
affection, and I can only say, in general terms, that there is scarcely
any inflammatory or febrile disease in wdiich it may not make its
appearance, and without modifying in any way the nature, progress,
or termination of the original malady : but it must be borne in mind
that I am now speaking of the Miliaria crystallina, and not of the
M. rubra or the M. alba, which last I regard as identical with suda-
miria. Now the febrile diseases in the trahi of which miliaria
appears are often attended with no demonstrable, or at least with
no easily detectable local change, or present sucli difficulties in dia-
gnosis that their nature is apt to be misunderstood. Hence the
eruption of miliary vesicles, being an obvious and striking feature,

390 MILIATIIA.

has been regarded as characteristic of the complaint. These cases
have ill fact been ascribed to a special exauthem^ which has been called
miliaria, and supposed to be a substantive disease, whereas it ought
to have been looked at as merely a concomitant exanthematous rash.
In support of this view, I may quote the testimony of Helm and
other physicians, who, at a time when the meaning attached to the
term typhus^ was not everyAvhere the same, practised in Italy or in
other countries in which correct opinions, based on pathological
anatomy, had not yet found general acceptance. For these observers
recorded cases of tj-phus in which the diagnosis was confirmed by
post-mortem examination, and in which numerous mihary vesicles
had been present : but they found that their professional brethren
regarded such cases as instances of " Fehris miliaris," and not of
tj^ihus. A similar explanation may be given of the affection known as
the Miliaria puerperalis. It is not a long time since the real nature
of the morbid process which gives rise to puerperal fever was first
made clear by pathological investigations. But, before this was
discovered, such cases, when accompanied by a miliary eruption, were
regarded as belonging to a substantive fever, which was termed
MiKaria. At the present day, these views arc as obsolete as tlie
notion which formerly prevailed that the milk was liable to undergo
metastasis to the skin (Galactophlysis, Galactidrosis), and to the
meninges, the brain, and other internal organs.

Miolocjy. — There are, to all appearance, such Ande diff'erences
between puerperal fever, typhus, and the other complaints m the
course of Avhich the M. crysialUna occurs, that Ave camiot suppose
the cutaneous affection to be due directly to the same agency which
gives rise to the primary disease. On the contrary, we conclude
tliat it is during the progress of this that the exciting cause of the
miliary rash is developed. And since Ave observe that the miliaria
appears, not at the cormnencement of the primary disease, but only
at a later period of its course, or even Avhen it has come to an end,
Ave may naturally suppose that this pathological process is itself the
cause of the morbid condition which gives rise lo the eruption.
Now it is observed that shiverings are a frequent precursor of this
cutaneous affection, and that in many cases (as, for example, in
puerperal fever) it is connected A^dth purulent infection. Indeed,
deposits of ]jus are sometimes actually present Avhen the miliaria
' See foot-note, p. 300.

DIAGNOSIS. 391

first makes its appearance ; and even wlien they are formed after-
wards_, the morbid condition which causes them always existed
before the rash was developed. Hence it is a reasonable supposi-
tion that miliaria is always the result of a pysemic process.

I do not conceal from myself the fact that even now no very
strict meaning is attached to the term pysemia, and that it is left
for the future to give a more precise explanation of this morbid
state. But there is no doubt whatever that the Bliliaria crystallina
developes itself only as a result of a morbid process of which the
conditions and symptoms are those of pycemia (so far as these are
at present kno"\ra and understood), and, therefore, that the existence
of this rash indicates the presence of pysemia.

Diagnosis. — At the commencement of my account of this disease,
I carefully laid down the distinctions between the M. nihra, the M.
alba, and the M. crystallina. The first two of these affections
I stated to belong to the Sudamina, and to be artificial eruptions,
produced by heat and sAveating. Now the description of these
varieties of miliaria will naturally come when I am speaking of the
etiology of eczema ; and, therefore, my principal object at present
is to define accurately tlie remaining variety, the M. crystallina, the
miliaria ja«/ excellence, and to give the marks by which it may be
distinguished from all similar eruptions.

There is no vesicular aff'ection in which the resemblance of the
vesicles to drops of dew is so marked as in miliaria, and the fluid
which they contain never becomes yellow and puriform, nor dries
into yellow or brown crusts. In fact, these vesicles are liable to but
slight changes. They do not coalesce with one another, but always
remain isolated; they are not arranged in groups; their base is
never reddened ; and they are never surrounded by a red border or
areola. - Again, parts which have been occupied by this afiection
are not subseqnently liable to be again attacked by them. Lastly,
miKaria is not attended with any subjective sensations of itching or
tingling ; indeed, no abnormal feelings exist to draw the patient's
attention to the presence of the eruption.

These peculiarities of the vesicles of miliaria, and the constant
existence of some other morbid condition which, in the present
perfect condition of our means of diagnosis, can generally be
readily determined, render it by no means difficult to diagnose this
affection. If the characters I have laid down be borne in mind, it

392 MILIARIA.

will be scarcely possible to confound miliaria with eczema^ herpes,
varicella, or the sudamiua proper.

Prognosis. — As this eruption is always a concomitant of some
general disease, or (according to the view which I have put forth)
of a pysemic condition, it becomes, in reference to prognosis, an im-
portant question whether the general disease is relieved or aggravated
by the breaking out of a miliaria, and whether its occurrence should
lead us to give a favorable or an unfavorable prognosis. Now,
experience shows that this vesicular affection may present itself when
recovery is setting in, and that it also appears in cases which termi-
nate fatally. So far as I know, indeed, no statistical data are in
existence from which one could determine the relative frequency of
death and of recovery in typhus, puerperal fever, kc, when attended
with miliaria. But in my oAvn experience and in that of my col-
leagues, the nmnber of those who have recovered from typhus, and
in whom this eruption has been present, has been about the same as
that of those who have died. There certainly is no abatement of the
symptoms when the miliaria breaks out ; but there is also no aggra-
vation of them ; and in the Vienna school of medicine, no pro-
gnostic signification of any kind, whether favorable or the reverse,
is attached to the occm-rence of this affection.

It is, in fact, perfectly inexplicable that medical men, as well as
the public generally, should have a dread of this eruption, and par-
ticularly of its supposed fugacity, and its imaginary tendency to
recede and give rise to metastasis. For, if there is any one eruption
which remains visible and unchanged after death, it is this. Other
cutaneous diseases can be detected in the dead body only when some
of then results (such as pustules, crusts, or hsemorrhagic spots) are
present, for mere reddening of the skin and slight exudative affec-
tions disappear even before death. But the vesicles of miliaria
present the same appearance in the dead body as dming life.
They are most easily detected on the sides of the chest, and on
the skm of the axilla. Yet it is a common popular remark, and
there are many text-books in which it is still laid down, that the
recession of this rash is, in certain cases, the cause of sudden death.
I have already, when describing the Ansemise of the Skm,^ expressed
my opinion with regard to the appearances supposed to be due to
the recession of various diseases, and have shotim that they are

^ Vide p. 70.

TREATMENT. 393

generally tlie result of an angemic state of the cutaneous blood-
vessels. But in miliaria no hyperemia at any time exists^ fluid merely
being collected in di'ops beneath the epidermis. Hence it is easy to
understand that the vesicles remain visible even in the dead body.
To me_, then, a metastasis of this eruption to the internal organs is
a thing altogether unkno-\^Ti. In fact^ I regard it as being itself due
to the formation of metastatic deposits in the skm.

Treatment. — I have shown that miliaria is a subordmate affection,
which accompanies other diseases without in any way modifying
their course, is itself liable to no metamorphosis of any kind, and
always terminates within a short time; and thus I have already
indicated the principle on which I would have it treated, and which
I may express in a single word, as being one of " expectation." I
am the more confirmed in this opinion, because miliaria gives rise to
no pain which might demand for this affection a special treat-
ment.

Thus, I neither desire to bring out this eruption, since experieuce
shows that it in no respect relieves the other symptoms from which
the patient may suffer ; nor do I, following the example of Schönlein
and his school, think of fixing it, for I do not dread its disappear-
ance or its supposed tendency to recede. In fact, so far as thera-
peutics are concerned, I altogether ignore the existence of miliaria.
I treat the patient on account of his other symptoms exactly as if
it Avere absent. In particular, I may mention that when the primary
disease (as, for example, an attack of acute rheumatism) demands
the application of cold lotions, or even of bags of ice, I should not
allow the presence of this eruption to prevent my employing them.
Tor, in the Wards of Professor Skoda, I have repeatedly had occa-
sion to observe that applying ice-bags for days together over the
joints, or even to the cardiac region, does not interfere with the
formation of the vesicles of miliaria, which are under these ch-cum-
stances just as fully developed as in cases in which Avarm poultices
are employed ; nor have I seen patients derive any injury from the
application of cold.

I must urgently protest against the employment in this affection of
any local irritants, including even the warm lotions recommended
by Schönlein, consisting of half an ounce or an ounce of caustic
potass dissolved in eight or ten ounces of water. For although a
miliaria cannot be brought out by such applications, I am sure that

39J^ PEMPHIGUS ACUTUS.

cutaneous irritants^ and] particularly such strong solutions of potass,
may give rise to an artificial eczema ; and this at least has the dis-
advantage of burdening the patient (who has already enough to bear
in the primary disease from which he suffers) with a new skin affec-
tion, attended wdth itching; whereas the miliaria alone would not
in any "way trouble him.

III. Pemphigus acutus seu febrilis. {Blasenfieber)

We frequently read in works upon diseases of the skin, as well as
in the medical journals, descriptions of an affection termed Pemphi-
gus acutus, which is said to pass through regular stages [Stadia
proclromorum, erupiionis, floritionis, decrustationis) like the exanthe-
mata, to termmate within four Aveeks at latest, and to have no ten-
dency to relapse. Now I have never been so fortunate as to meet
with a pemphigus presenting these characters ; and I base this
statement not only on the patients under my own care (of w^hom the
number now exceeds 80,000), but also on the experience of all my
colleagues in this city, whether in the General Hospital or in the
other institutions for the sick. This, for a period of more than
tw^enty years, represents such an enormous number of patients, that
one may estimate them at about a mulion. Now among these cases
no single instance of an acute typical pemphigus running its com'se
after the manner of the exanthemata has as yet presented itself. I
do not mean to affirm, that one or two bullae may not now and then
develope themselves, and, after remaining a short time, disappear
without being foUoAved by others. This may be observed either in
persons previously healthy (although it is a rare affection, imless
caused by some local irritant), or in patients suffering from febrile dis-
eases, and particularly those due to blood-poisoning, such as puerperal
fever, continued fever, variola, &c. In such maladies, the formation
of a few scattered bullae may occur as a result of metastasis. But
to warrant us in making use of the word pemphigus, there ought to
be something more than an ephemeral bulla. In tlxis, as hi all other
cases of diagnosis, we have to distinguish between symptoms and
diseases, between the import of a single bulla and that of several.
In all questions of this kind, oiu" conclusions must be based upon
the course of the complaint, and the way in which its symptoms
succeed one another. No one would thmk of saying that variola

PEMPHIGUS ACUTUS. 395

was present because there were two pustules at some part or other of
the surface^ or of declaring a patient to have cholera because he had
been purged and had vomited once or twice. Nor have Ave any
greater right to assert that a case is one of pemphigus, because a
single bleb is present. I cannot admit the vaHdity of such a
diagnosis,, unless the case really ansM^ers to the description which
has been given by writers upon this disease.

The causes which have led to the idea that there is an acute
exanthematic pemphigus are probably the following :

1. The ephemeral bullae which make their appearance in various
other diseases, such as variola, have been ascribed to a 'PemjpMcjus
acutus.

2. The Varicella bullosa, and those forms of herpes (particularly
the H. Iris) in which the vesicles frequently pass into bullae, have
been regarded as belonging to pemphigus.

3. The different eruptions of bullae which characterise chronic
pemphigus, and each of which is often of no very long duration,
have been mistaken for instances of an acute form of the disease.
When describing chronic pemphigus, I shall treat of this point at
greater length.

4. Urticaria, not only in its acute, but even in its chronic form,
sometimes presents the peculiarity that, instead of wheals, bullae are
formed at certain spots. But no one need be astonished at this
exceptional occurrence who bears in mind that wlieals themselves
result from the pouring out of serum, and that an increase in the
quantity of fluid is all that is necessary to raise the cuticle over
a wheal and to form a bleb. That this was known even to the older
writers, is proved by the expressions, " Urticaria vesiculosa^ U. bul-
losa," which we find in medical literature.

5. Erysipelas is well known to be sometimes attended with the
formation of bullae of various sizes, which are, however, confined to
the original seat of the disease, never spreading to the adjacent un-
infiamed parts of the skin. The name Eri/sipelas vesiculosum et
bullosum has long been used to designate this form of the affection.

6. Lastly, mfants are Hable to a cutaneous affection in which
bullae are formed, and which, like every other infantile disease, runs
a much more rapid course, than in adults. That such cases have
not been regarded as instances of chronic pemphigus has been merely
because duration alone is looked on as determining w^hether a com-
plaint is acute or chronic. But surely no one will assert, that

396 PEMPHIGUS ACUTUS.

because the FempMgus syphiliticus neonatorum terminates very
rapidly by the death of tlie child affected with it, the affection is
therefore a P. acutus ; and what I say of this syphilitic disease is
true also of all the other bullous eruptions to which children are
liable,, and which have been spoken of by medical writers mider the
name of Rupia escliarotica, or FcBilojMi/ciis.

I think, then, that I am justified in adhermg to the opinion stated
above, and that doubts may fairly be entertained as to the existence
of a Tcmpkigus acutus {Fehris pemphigosa, bullosa, ampullosa,
Epinyctis, Thermintus, kc).

I would advise those who may wish to refer to books upon this
point to consult not only the well-known demiatological treatises of
Willan, Bateman, E. JFilson, S. Plutnbe, Älibert, Cazenave et
Schedel, Ray er, Fuchs, J. Frank (Band i, p. 137)^ Bevergie,
Gibert, Buchesne-Duparc, kc, but also the following special works :
'Ideen zur Diagnostik,' von /. F. Wichmann, Hanover, 1794
(Band i, p. 82) ; ' Versuch über den Pemphigus und das Blasen-
ticber,^ von C. G. C. Braune, Leipzig, 1795; 'Monographie du
Pemphigus, ou Traite de la Maladie vesiculairc,' par Gillbert, Paris,
1813 ; ' Annales des Maladies de la Peau et de la Syphilis, pubhees
par A. Cazenave, vol. iv, Mars, 1852, p. 141; ' Ucber die Uji-
zulänghchkeit der bisherigen Pemphigus-Diagnose,' von Br. A. La-
famme, Würzburg, 1856. In the last-mentioned work the reader
will find, at page 1 2, a detailed account of the literature of this
subject.

FEINTED BT J. E. ADLAED, BARTHOLOMEW CLOSE.

V /

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